Nurses on the fly

Florence Pwana saw a disturbing but unsurprising sight when she walked into an empty makeshift tent at the Shuwai 2 camp for internally displaced people. The camp rests along the outskirts of Maiduguri, capital of Nigeria’s Borno state. Hours earlier, a resident at the camp helped to deliver a baby in the tent, and some of the camp’s residents showed Pwana the exact location where the woman lay on the floor, traces of blood still visible.

Shuwai 2, which is not registered under the state government, has no health dispensary: The nearest health facility is about 60 miles away. Pwana, a volunteer project officer with the Traffina Foundation for Community Health, said the birth attendant had no prior experience besides handling her own births.

In the town of Bwari along the outskirts of Abuja, Nigeria’s capital, Traffina volunteer Janet Yunana witnessed similar events. Yunana said local birth attendants sometimes lay expectant mothers on the floor or on plastic bags during delivery. “We’ve seen a woman who gave birth on her own, and she was using a broken bottle to separate the cord from her and the child.”

According to the World Health Organization and the UN, Nigeria has the fourth-highest maternal mortality rate and the third-highest infant mortality rate in the world. At least 50 percent of the country’s estimated 190 million people live in rural areas. In many of these regions, many women give birth either alone or with the aid of attendants whose qualifications are their own home deliveries.

Health workers trying to tackle the crisis realized blocking off these traditional birth attendants (TBAs) would only leave more women without assistance. Some are opting instead to train the TBAs as a midpoint solution until Nigeria’s healthcare system becomes efficient.

Lois Ahmed, one of the traditional birth attendants in Bwari, became the go-to birth attendant in her community after she delivered five of her six children herself. Ahmed said she began to offer her services long before her Kogo village received a government-run primary health center.

Most times, her method is simple: Once she receives a call, Ahmed checks if the cervix is “open” and begins the delivery. When the baby emerges, she cuts the placenta, then cleans and feeds the baby. Ahmed urges mothers to go to the clinic by morning. If a woman who calls her still has some time before labor, Ahmed sends her to the hospital.

The details of the TBA process vary. Jumai Solomon, another TBA, said she uses a razor blade to cut umbilical cords. Pwana said she has seen other TBAs use a piece of thread, which could either get contaminated or loosen, in place of a cord clamp.

WARIF founder Dr. Kemi DaSilva-Ibru speaks at a TBA training session. Handout

Despite the risks, TBAs are often the closest help for women when labor begins. Delivery costs also affect women far from any subsidized primary health center: “Some of them don’t have money to open hospital cards, purchase medicine, or pay for the bills, so they prefer to go to a TBA,” Pwana said.

Understaffing at some primary healthcare centers is also a problem. A single-story center with only three full-time staff members serves the village of Peyi and two other villages within Bwari. The limited staff means the clinic closes at night. Dr. Haruna Isa, the clinic’s director, said women who go into labor at night would rather call a nearby TBA than contact staff at the health center.

Expectant mothers also choose where to deliver based on trust. Pwana met women who fear what doctors at hospitals would do to their children. Dr. Abraham Idokoko, a Nigerian public health analyst, said people sometimes view hospitals as a bad omen. “We have a very religious community,” he said. “We don’t look at the physical aspect first.”

Groups like Traffina Foundation considered these factors and modeled a response. The foundation has trained at least 115 TBAs across Nigeria. The TBAs learn how to deliver a child properly in emergency situations and care for both mother and child immediately after delivery. The training emphasizes immediate referrals for postnatal care: Traffina staffers said they tell TBAs like Ahmed to send the women to any of their partner clinics once they notice complications during labor.

Traffina also equips expectant mothers with delivery kits that include cord clamps, gloves, and a mucus extractor, among other amenities, all stacked into a small green bag. After attending TBA workshops, Ahmed said she started to wear hand gloves during deliveries.

The foundation holds community awareness sessions on issues like HIV/AIDS and how mothers could transmit it to their children. Traffina involves community leaders, including area council chairmen and traditional and religious leaders, into their campaigns to help counter health misconceptions.

Dr. Kemi DaSilva-Ibru believes TBAs can serve another important role. DaSilva-Ibru in 2016 set up the Women at Risk International Foundation (WARIF) to respond to cases of rape, sexual assault, and trafficking among young girls and women in communities across Lagos and other states. She says TBAs act as “gatekeepers” of communities since women often trust them more than health professionals. Last October, the foundation started to train 500 TBAs to recognize the signs of gender-based violence, how to offer responses, and the process of referring emergency cases.

The training has started to bear fruit: TBAs made up 20 percent of the phone calls reporting abuse cases between October and December.

Idokoko sees the efforts to train TBAs as a necessary but temporary solution. The process is not foolproof: Dr. Isa said some TBAs remain hesitant to identify themselves. “They’re afraid they would not get clients again.” Idokoko said part of the long-term solution could include a revamp of the primary healthcare system, which is in dire need of human resources.

In a 2016 investigation, the Nigerian International Center for Investigative Reporting revealed that a majority of Primary Health Centers built across Nigeria between 2014 and 2015 remain unopened or lack adequate drugs and staff. “The government, particularly the local governments, should aggressively drive the implementation of Primary Healthcare according to the books in a truly bottom-up approach,” Idokoko said.

Back at the Primary Health Center in Peyi, Ahmed said she has attended a total of three workshops. She learned more about her limitations in helping with deliveries and continues to grow her relationship with her community’s health centers: She sometimes assists the nurse during labor in the short-staffed health center. Ahmed said her priority remains learning “how to perfect the delivery.”