Wednesday, August 31, 2011

Providing pregnant women access to emergency care in northern Nigeria

Drivers demonstrating how they transport a woman
(with a scarf) in labor into their car.
Nigerian women have a 1 in 23 lifetime risk of maternal death, and the country's maternal mortality ratio is the 9th highest in the world. With roughly 50% of Nigerians living in rural areas, cost and lack of physical access are two of the major barriers to Nigerian women having access to maternal health care.

The northern region is particularly burdened. As it is more rural, with lower education rates and certain cultural practices, women in the north tend to have less access antenatal care and are less likely to give birth in health facilities than in southern regions.

A user of the Emergency Transport
System (ETS)
Loosing a mother during childbirth is a reality for many in northern Nigeria, and it doesn't just effect individual families. Maternal deaths deeply impact communities who often feel (and, in reality, are) helpless to stop them. I worked for two months with the Partnership for Reviving Routine Immunizations in Northern Nigeria – Maternal, Child and Newborn Health (PRRINN-MNCH), based in northern Nigeria, and saw firsthand how they are working with local communities to break down some of these barriers.

In the communities in Zamfara state where I was living, increasing access to maternal health is incredibly complex. Not only does it require access to cars and passable roads, but the cars must work and have fuel, families must know where to find the drivers if the need them (which may require a phone), communities must be educated on when you need to go to the health facility and why, and the health facilities must be staffed, with the drugs and tools necessary to deliver a child.

And these are just a handful of the barriers I saw.

Through a variety of access programs, PRRINN-MNCH is working to break down some of these barriers. Two years ago, it launched the Emergency Transport System (ETS) program in the 4 states where it works. Using commercial drivers who volunteer their services, ETS provides pregnant women with emergency transportation to a health facility when they need it. Many women who have used ETS thus far, if not most, were suffering from excessive bleeding or were already unconscious when the ETS driver was called.

While their children did not usually survive, without ETS these women would not have either.
Calling a commercial driver would have been out of financial reach. Commercial drivers often charge extra to transport women in emergency situations. Combined with the hospital fees, these costs can make a family choose between food and basic survival and going to the hospital. In describing what he liked about the program, one community leader stated, "We are helping ourselves."

Despite these successes, a big question remains: Without financial incentives for drivers, health facility staff and community volunteers, is ETS sustainable?

Ambulances do exist, but a functioning ambulance system in Zamfara is far off. It's clear that finding an alternative is imperative to improving maternal health outcomes, and ETS has been the best alternative in the locations where it operates. Yet, ETS drivers often use their own money for fuel and loose commercial customers when transporting a woman. Their work is inspiring and admirable and they are undeniably proud to be volunteers and ETS drivers, helping their communities. Speaking with them, most of them said they do not want anything in return for the services they provide. They are helping their communities and believe they will be thanked in the afterlife for their work.

Focus group of women who used ETS
However, even with all of this they still need to provide for their families. How long will it be until the financial burden on them is too much? At what point will mothers be left to die?

PRRINN-MNCH isn't willing to wait to find out. In a few months, a series of incentives will be piloted for ETS drivers, health facility staff and community volunteers. The goal is to understand whether they work, amidst fear that providing monetary incentives, however small, will alter the altruistic spirit of the program. If drivers are seen as gaining personally from helping women, will they lose the sense of pride they have in helping the community? If so, will the program become less effective? These answers will help improve the ETS program in northern Nigeria and provide a model to improve global maternal health outcomes.

- Laura Baringer, MPH/MPA '12, Population and Family Health

August 31, 2011