Midwives promote respect between staff, patients and communities to reduce maternal deaths

Of the approximately 7.5 million people living in Jigawa State, it is estimated that up to 90 per cent live in rural communities with their livelihoods based in agriculture and livestock. Most rural villages have some form of primary schooling available, though poverty and the need for children to help with farming or care of livestock means attendance is not universal. For girls, cultural and social factors can impede their education further.  

Lower educational attainment impacts health literacy and awareness around the danger signs in pregnancy and when to seek medical care. Certainly, women present to Jahun General Maternity in advanced pregnancy or labour crisis having exhausted the treatments and remedies available at home from traditional healers and herbalists. The faith in trusted traditional birth attendants and strong cultural preference for home birth surrounded by loved family members also delays transfer to hospital. Securing permission to seek medical help from the male head of the family, who is considering multiple competing priorities, the weight of immediate versus future wellbeing, and use of often severely restricted resources can further delay transfer.

Listening and responding to community needs

MSF reaches rural communities through engagement with respected community and cultural leaders creating networks to share health education and improve health literacy. These networks also create trusted channels for communication of what people need from MSF, to share their experiences of health services and better understand community perspectives, needs and the reality of seeking maternity care.  

For example, a network of women’s ambassadors has been established in rural villages. They deliver key sexual and reproductive health education and messages like how to recognise danger signs in pregnancy and when to seek medical care. Through feedback from them we learnt that women believed taking iron and vitamin supplements in pregnancy would make their baby grow huge, causing childbirth to be more perilous. They were avoiding taking vital supplements to reduce anaemia. Through these channels, immediate concerns and myths can be dispelled and real health strengthening supported.

MSF health promotion teams are based in both the community and Jahun General Hospital. Where people gather—waiting relatives as well as new mothers with their babies—they receive health education, nutritional advice, information on caring for the newborn, breastfeeding and contraception information. First-time mothers are a key vulnerable group and each contact with health services is an opportunity to empower them and their families with information and options. Knowledge radiates onwards through communities.  

We also learned, through nurtured relationships with community leaders, that when women present to rural hospitals they are often spoken to harshly, chastised for arriving late and for their lack of health literacy. Providing respectful maternity care addresses these barriers to seeking care. A primary function of my role was to engage teams with thoughtful reflection on the interface between frontline staff and patients. Together with my counterpart in the community, we embedded welcoming receptions, gaining consent, drawing curtains during intimate examinations, and respect of personal dignity and privacy. All these preserve humanity, to ensure women and families will seek timely care when they need it. 

Improving access to care when roads become barriers

The 22,500 square kilometres of Jigawa State has sparse sealed roads and people face a lack of transport options. These are significant barriers to reaching maternity services. Roads are disintegrating in parts. Many women arrive via motorbike after hours of slow and uncomfortable travelling from their village over crumbling, potholed roadways. During the three-month rainy season there are also swollen waterways that must also be negotiated. Some women only reach hospital after days of protracted labour, or in a state of severe illness.

MSF identified and supports four Ministry of Health (MOH) primary hospitals located on main thoroughfares across Jigawa State to enable early access to initial care. We also maintain a functioning reliable ambulance at each facility. The Iveco Daily ambulance that is based at Jahun General Hospital makes the drive between the Jahun primary hospital and our specialist obstetric and neonatal services in around seven minutes each way. The primary hospitals manage normal births and, with robust referral systems in place, promote early transfer of high-risk pregnancies. Communication pathways are always being honed to ensure Jahun General Hospital knows in advance of incoming emergency cases in preparation for delivery of swift, often lifesaving care on arrival. All MSF ambulance services and MSF supported MOH maternity services are delivered free of charge, reducing the often-prohibitive financial barriers to care. 

Emergency and specialist care available 24/7

Emergency responses like access to surgical birth by caesarean section, blood transfusion and specialist care for critically ill mothers form the core of MSF’s strategy to address the third delay. This means any delay that hinders receiving appropriate and effective maternity care in a facility. The intensive care and neonatal care units are staffed by experienced and dedicated nursing teams and doctors. Specialists including a consultant anaesthetist and internationally and locally hired obstetricians are available 24/7.  

MSF’s ‘super’ midwives, many having worked for over 10 years with MSF, have amassed specialist skills for labour and birth including performing birth by vacuum extraction to urgently expedite delivery of a baby in distress. They respond consistently every day under high pressure to life-threatening conditions like eclampsia, sepsis or post-partum haemorrhage.  

As a team we are constantly reviewing practice and processes to optimise the care we provide. Feedback from the community, refresher trainings, maternal and neonatal mortality reviews and collaboration across the multi-disciplinary team drives services internally to address the high rates of maternal and neonatal deaths in this region. Externally, MSF project and partnership coordinators reach out to collaborate with regional and national government bodies. The advocacy for increased investment and commitment to improved healthcare provision, education and infrastructure continues.”