We are excited to launch our Maternal Health Heroes Summer Series with an interview with H.E. Mrs. Toyin Saraki, founder of the Wellbeing Foundation Africa. Throughout the summer we will speak with some of the most notable maternal health advocates in the world ahead of the Global Maternal Newborn Health Conference that will be held in Mexico City between October 18 – 21, 2015. Follow the conversation at #MHHSS.
When did you know global maternal health was a bigger issue than you previously realized?
I became aware of the serious issues surrounding maternal health and survival over 20 years ago, when I gave birth to twins in Nigeria. I tragically lost one of my twin babies during childbirth, and then had to fight for the survival of the other. Even though I was an educated and informed woman, I was unable to save the life of my stillborn second twin daughter because of the infrastructural deficiencies in Nigeria’s healthcare system at the time, including a fatal delay in finding an anesthetist for an emergency C-section. Although I was grateful to leave this painful experience with my first twin and my own life, I realized that this experience is an unavoidable reality for many women in Nigeria, and indeed across the world.
Globally, approximately 800 women die from preventable causes related to pregnancy and childbirth every day, and 99% of these deaths occur in developing countries. And, where a mother suffers, her child suffers; and more than 3 million babies die before they are a month old. I founded the Wellbeing Foundation Africa to help address this heartbreaking issue that affects so many women and children. At first, my view was much more localized and I did not know all of these global statistics and the injustice that was taking place on a daily basis; but now it is these statistics, and the real life stories behind the statistics, that spur me on to continue every day.
How do you believe we can achieve substantial improvements in maternal health?
Midwives are absolutely crucial to achieving substantial improvements in maternal health. Midwives empower mothers to make life-saving choices for their children before, during, and after childbirth. A skilled midwife can provide expert care that ensures the survival of newborns during the first fragile 24 hours of life, and enables them to not only survive, but also thrive well into childhood. Midwives empower women at a time when their health is at its most vulnerable. Midwives empower women in a way that can help shape the future health of both mother and baby. After all, we know that an empowered woman is a health-seeking woman for herself, her family and her community.
Midwives should therefore be placed at the very center of Sustainable Development Goals (SGDs) targets related to reproductive, maternal, newborn, and child health. Without this focus, the international community may fail to meet their targets and achieve sustainable improvements in maternal health across Africa and the rest of the world. This is why I am so honored to represent midwives on a global scale as the Global Goodwill Ambassador for the International Confederation of Midwives (ICM). Further to this, I am proud that the Wellbeing Foundation Africa has been awarded consultative status at the United Nation’s Economic and Social Affairs Council (ECO-SOC), where we will work to make sure that achieving substantial improvements in maternal health is a priority for the international development community, especially in this pivotal year.
When you talk to frontline health workers, what are their main obstacles when providing quality maternal health care?
A key issue that is often a challenge for frontline health workers is tackling the stigmas facing women during pregnancy and childbirth. Often, women will not seek out help during their pregnancy because they are either embarrassed or afraid, or simply unaware of the help that they need. To this end, WBFA believes that effective health communications can break down these stigmas and enable women to seek the help that they need. Overcoming this requires communications training for healthcare professionals, like midwives, that can not only ensure that women are listened to, but are fully aware of what they need, and what they are entitled to. This is the very foundation of Respectful Maternity Care – making sure that mothers are heard, informed, and empowered.
Another serious concern raised by health care workers in Nigeria is a lack of patient records. Data collection in a country as diverse and large as Nigeria is fraught with difficulty and we lack coherent data on maternal, newborn and child mortality rates. Despite existing legal provisions for birth and death registration, registration numbers are exceptionally low in Nigeria, with only a third of all newborns registered at birth. Death registration figures are even lower, with just under 12% of households surveyed registering deaths in the last 10 years. Without accurate records, we will struggle to accelerate national progress on reducing mortality rates or have a meaningful understanding of how to efficiently implement the Sustainable Development Goals.
Crucially, for medical staff, a lack of accurate patient records means that they cannot effectively identify health risks in pregnancy or track patient progress. For patients, a lack of accurate records means that they cannot track their own progress during pregnancy, leaving them without vital life-saving information, such as their blood type or medical history.
Learning from this situation, WBFA introduced the client-held Personal Health Record (PHR). The PHR has been designed to be in the custody of mothers so that they can bring them to health centers during their pregnancy and labor, and up until their child attains the age of 5 years. Keeping all of this information in this client-held PHR is an effective way of ensuring that mothers and children receive the right care throughout the periods of pregnancy, labor/delivery, and post-natal care.
The PHR is groundbreaking in Nigeria because it is far more than a data collection tool – it is an information delivery platform. It empowers women to track their health and the health of their children, including their nutrition, immunization, and more. It provides healthcare professionals like midwives, with an early warning signal, in case of any risks during pregnancy and in the early stages of childhood, and enables them to provide timely care and advice to mothers and their families. Also, as a vital audit tool, it can identify gaps in practice and improve quality of care.
Indeed, in a recently released report, the World Bank, USAID and the WHO highlighted how personal health records were a critical component of effective measurement and accountability systems for health, claiming that ”client-held personal health records, especially for mothers and children, can build ownership of health information as well as consistency of data over time and across different facilities.”
How do you believe women, especially those who live in rural areas, can best be convinced to deliver their babies in a hospital or health center setting when they are used to delivering at home?
In Nigeria, we are facing serious challenges regarding the provision of maternal health services and facilities in rural areas. Financial barriers, scarcity of skilled birth attendants, and lack of awareness about the services that are available to them, have led to 14% of Nigerian women giving birth without anyone present, not even a family member. And this is a trend that is actually getting worse in rural areas, as in the case of the North West Nigeria, where there was a 27% increase in the number of women giving birth completely alone. Considering that northern Nigeria suffers from the highest maternal mortality rates in the country, scaling up access to maternity care in rural areas must be a priority to ensure that mothers are no longer giving birth by themselves.
Much is made of the scarcity of doctors in Africa but equally worrying is the lack of midwives on the continent, and their skewed distribution within countries. Low remuneration and poor work conditions continue to lead to a ‘brain drain’ of health workers like midwives, in rural communities. Therefore, I believe that we must prioritize access to midwives within these communities to ensure that young mothers no longer feel alone and alienated whilst giving birth.
Overcoming the challenge of convincing women in rural areas to deliver their babies in a health facility must also consider how we fund health services in communities. When we began our work over a decade ago, the Wellbeing Foundation’s frontline health programs included the Positive Lifeline Programme, Twins and Multiple Births Programme and the Indigent Medical Fund, which helped thousands of lives. Through these three programs, the Foundation and I intervened to assist with out-of-pocket medical bills and the cost of specialist healthcare for patients in need. However, even we have found that this model, whilst successful, is ultimately unsustainable – we could not go to scale. We realized that fundamentally transforming how we approach primary healthcare as a nation, would require a more comprehensive and innovative financing mechanism.
Often, Nigerian women are unable to pay health insurance premiums, which means they are forced to rely on expensive emergency care services. With just under 50% of Nigerians living below the poverty line out-of-pocket financing at the point-of-service in hospitals can cripple families financially for years, resulting in further economic vulnerability and limited access to regular primary healthcare, setting off a cycle of poverty and poor health for generations. Access to affordable health insurance could be the difference between life and death for these families, particularly during pregnancy. It will prepare families for the cost of healthcare, allow families to access regular primary healthcare physicians at a low-cost, and encourage women to deliver their babies in a hospital setting. This is why the WBFA initiated the Alaafia Universal Health Coverage Fund (AUHCF), which will pay the insurance premiums for 5000 people each year.
We must also consider solutions that help mothers who choose to deliver their baby at home to do so in a clean, safe, and prepared way. Therefore, WBFA has developed Safe Delivery Kits, which we affectionately call ‘MamaKits’, that provide women with all the necessary health commodities that they need to transform any incidental delivery location to the likeness of an equipped health facility. Access to MamaKits will help save the lives of women in rural areas who are unable to or choose not to access maternal health facilities.
What are some of the programs (feel free to include yours) that you know of and have visited that are making great strides in maternal health and survival in Africa or elsewhere?
For me, a personal standout achievement was the adoption of Personal Health Record (PHR) into the very frontline of the Nigerian health system, through the Midwives Service Scheme (MSS) of the National Primary Healthcare Development Agency (NPHCDA). My vision is to ensure that every woman and every child in Africa has an individual PHR and my intention is not to stop until that is so. With the PHR, we can put a life-saving tool in the hands of every mother. As a vital audit tool, the PHR tracks crucial health data, empowers women, and ensures that health care workers can deliver the best possible care to save the life of the mother and child. I truly believe that this simple tool will make great strides in maternal health and survival on the continent. Also I believe that making the shift from plugging the gaps in our health infrastructures to a sustainable health care system will be the most crucial step in transforming maternal health and survival on the African continent.
For many women around the world, preparation for birth means nesting, painting nurseries, and attending antenatal appointments. Yet, for pregnant women in rural areas of Nigeria, preparation for birth is ensuring they take at least 12 candles and six gallons of diesel with them to the hospital, lest the facility suffer a power cut during delivery. Included in a preparation for birth list given to women in rural areas, the candles shine a light on glaring gaps in Nigeria’s health system and infrastructure, and the need for an approach that tackles inequity of access to adequate medical resources and social determinants of health. The establishment of community-based health insurance schemes like the WBFA’s, Alaafia Universal Health Coverage Fund (AUHCF), is vital for placing communities on the path to universal health coverage, and most importantly, information and accountability, in a sustainable manner.
Visit The Wellbeing Foundation at www.wbfafrica.org.