Toyin Alade cleans her own home every morning before hurrying off to visit the homes of pregnant women in the outskirts of Akure, a bustling city in the southwestern Ondo state of Nigeria.
Alade, 45, does not wear scrubs. Nor does she carry surgical gloves, syringes, or needles. The closest thing she wears to a uniform is a reflective orange vest embossed with “Abiye vanguard” — and a gaze so stern it is unfazed by the challenges of her task.
The short-haired woman sold household goods like soap, toothpaste, candies, pencils, and ballpoint pens until 2014, at which point she learned about the Abiye vanguard, a kind of ward monitor that travels house to house to monitor pregnant women and the care they receive. She is now one of 400 health vanguards in Ondo who help ensure that all pregnant women deliver at a health facility with the assistance of a skilled birth attendant.
The position was created to help Ondo State reduce the high rate of maternal mortality in the state. “I am happy to help my state tackle this crisis,” Alade exclaimed, her eyes aglow. “It is a calling.”
Ondo’s journey to tackling maternal mortality began in 2009 when it piloted a safe motherhood program called Abiye, which means “safe motherhood” in Yoruba, a dominant language in southwestern Nigeria. The program was introduced after former state governor Dr. Olusegun Mimiko said that he would no longer tolerate the growing rate of deaths of pregnant women and newborn babies.
At the time, Ondo State had the worst maternal and child care indices in the southwestern region. Its maternal mortality ratio was 742 per 100,000 live births, compared to Nigeria’s national average of 545. This high rate was caused in part by lack of funding, personnel, and equipment in health facilities. In addition, most women, especially in the rural areas of the state, preferred to deliver with a traditional birth attendant instead of a skilled one.
The program got in full swing after the state conducted a baseline survey in 2010 to determine the causes of maternal death.
After gathering data and conducting in-depth interviews with relatives of the deceased, the committee revealed 90 percent of the deaths were due to delays from traditional birth attendants seeking medical care for their clients.
(At the time, only a handful of women in Ondo gave birth in a health facility; over 80% relied on unskilled birth attendants who usually don’t have the capacity to address complications during labor.)
State authorities realized they needed to focus their efforts on fixing the “three delays” that cause maternal mortality — i.e., (1) a patient delaying their decision to seek medical care, (2) delays in physically reaching care due to poor infrastructure, and (3) delays receiving adequate care when a facility is reached.
TThe government program, funded by the state with some support from the World Bank, started with campaigns to help pregnant women get to grips with the dangers of delivering at home. They also trained “health rangers” to each monitor at least 20 pregnant women in their ward (an administrative unit of local government).
The health rangers helped women register with health facilities, prepared birth plans, and accompanied them to antenatal appointments. The government provided transportation for the health rangers — motorbikes and a fleet of ambulances — to ensure that women easily reached health facilities without delays.
Finally, Ondo state upgraded and refurbished primary health facilities, providing medical supplies and personnel trained in safe delivery practices, emergency obstetric care, and newborn care. It also created two hospitals to handle emergencies and referrals.
Put together, these strategies did not take long to start yielding fruits. In 2012, just two years after the program began, a report by the committee of inquiry showed that the state’s maternal mortality rate decreased by about 40% from 2008.
FFive years after the Abiye project, the state did not rest on its laurels. In September 2014, it launched a program called the Agbebiye, or Safe Birth Attendant initiative, in the hopes of keeping maternal and infant mortality on a downward spiral.
Agbebiye is an offshoot of Agbebi, the name for traditional birth attendants in Yoruba. The state coined the term Agbebiye to refer to the traditional and home birth attendants working with the government to reduce maternal mortality in the state.
At the heart of the Agbebiye initiative is the goal to completely phase out unskilled traditional birth attendants, or TBAs.
Funmilola Oluwadare, the special assistant to the government on maternal death reduction, said she sought TBAs’ cooperation by urging them to put themselves in the shoes of mothers who died during labor and suffered serious complications or lost their children.
“Some of these TBAs don’t know the implications of the death in their homes because they see it as an act of God,” Oluwadare said, her back slumped over a couch. “The journey towards phasing out the role of TBAs was rough, tough, and stressful.”
The state offered TBAs 7,000 naira ($6.50) each time they referred expectant mothers to health facilities to give birth, instead of delivering the babies themselves. It also offered TBAs trainings in new trades like bead-making, soap-making, catering, and tie-dying.
“We also offered them microfinance loans to help them set up small businesses,” Oluwadare said. “The interests for the loans were paid by the government. In some communities, some TBAs got up to 100,000 naira ($325).”
The government also employed people like Toyin Alade to monitor TBAs and enforce compliance. The state warned that TBAs who continued their operations would be fined and their homes locked up.
According to Oluwadare, the vast majority of TBAs have now abandoned the trade and are now working with the government to eradicate maternal mortality. “I don’t allow women to deliver in my premises,” said Omonilale Fasakin, the president of Ondo’s TBA association. “Instead I take them to the health facility.”
Margaret Oyewole, who also used to work as a TBA, said she was happy to work with the government to reduce maternal mortality completely. “We enjoy a smooth relationship with nurses, doctors and other health workers,” she said. “They no longer see us as quacks but partners in progress.”
Ondo State health commissioner Dr. Dayo Adeyanju said that 94.7 percent of deliveries today are now handled by skilled attendants, compared to 38 percent nationwide. By 2016, Ondo’s maternal mortality rate dropped dramatically to 112 per 100,000 live births (for comparison, the corresponding figure for Nigeria as a whole is 814).
TThe program’s success is partly tied to the fact that state officials didn’t adopt a one-off approach — rather, it approached maternal mortality from multiple angles.
It also sought community cooperation and participation by involving locals as ward monitors or vanguards and used influential community members like traditional rulers, religious leaders, ward development committees, market women, and chairmen of local government areas.
“Maternal mortality is a huge issue, and the state government cannot solve it alone,” Adeyanju said. “We had to involve almost every important group and leaders to change the situation — and it all worked out in the end.”
There was also a strong demonstration of political commitment from Ondo’s governor and his team. They showed how serious they were with the crisis by devoting up to 12 percent of the state’s overall budget to health — about triple what it usually spends.
Nationally, support is not nearly as robust; this year, the federal government allocated around $957.5 million (4.17 percent) of the national budget to the health sector, a little above the 2016 budget of 4.13 percent. This falls short of the agreement among African countries in 2001 to allocate at least 15 percent of their budgets to health care.
Ondo’s success has attracted a slew of recognition both locally and abroad. The state governor, Dr. Olusegun Mimiko, discussed the Abiye Safe Motherhood program with members of the UN Assembly in 2013. The World Bank has called for the program to be deployed as model for reducing maternal mortality in Africa.
Other Nigerian states are also trying to address maternal death. For instance, Lagos, the commercial hub of Nigeria, is training TBAs to facilitate safe delivery. It also established a medical board to oversee the activities of the TBAs, and encourage TBAs to refer complicated cases to health facilities.
“In Lagos, the overall intention of the state government is safe delivery of newborns regardless of means of delivery, be it through modern day doctors or through TBAs who have been certified to operate by the state ministry of health and licensed,” the state ministry of information said in a statement.
Maternal and infant mortality remains a huge problem in Nigeria, and it follows that other states could have adopted the program and fine-tuned it to suit their local circumstances. But that’s not happening yet; Africa’s most populous country accounts for 10 percent of all maternal deaths worldwide.
According to Oluwadare, women from other states in Nigeria travel to Ondo State to deliver. She thinks it might be difficult to roll out the program to other states because “every state has different priorities and needs.”
OOn February 23, Mimiko handed over power to the incoming governor Rotimi Odunayo Akeredolu. Even before his second term drew to a close, he was among the 27 state governors who requested a federal bailout because there was no money to pay its workers, including its health workforce. Currently, hospitals across the state are closed as workers are on strike, demanding payment of salaries.
Financing, therefore, remains a potential problem to the longevity of the Abiye program. Though the project is funded by the government, the World Bank, and other development partners, it is unsustainable in the long term because many states are struggling to even pay salaries. This means that alternative funding sources must be raised immediately.
However, there is a bit of good news: the state commissioner of health, Adeyanju, said the World Bank has agreed to work with the state government to fund the Agbebiye initiative.
As to whether the program will continue even after Mimiko is gone, Adeyanju noted that community participation means the program was not going to fizzle out.
A quick look at Toyin Alade’s face reinforces the importance of the program. “I want to continue doing this job because I don’t want people to die,” she said. “People are excited about this program. I am staying with this until the end.”
