The GEANCO Foundation has intervened in the area of medical missions for orthopaedic surgery in Nigeria since 2011. In 2014, they began to focus on another area of health development -- maternal health and nutrition.
The Foundation wanted to reach out to underserved pregnant women who were likely to develop anemia in pregnancy because of poverty. "The first time many of them come, they are usually anemic. When you test them with the pulse oximeter, you will see someone almost due for delivery and the person is seriously anemic. It could be a problem if they enter labour in that state," says Paschaline Chukwuka, Nigeria In-Country Manager, GEANCO Foundation.
To mitigate this problem, GEANCO started an anemia control program at two private hospitals, Annunciation Specialist Hospital at Emene and Mother of Christ Specialist Hospital at Ogui Road, both in Enugu State. In 2018, the Foundation expanded their reach to government primary health centres in Enugu to reach more underserved women.
They started with Nchatancha-Nike Primary Health Centre. Chukwuka says the health centre at the time was comatose, with only a few women coming for immunisation. There were no routine antenatal activities going on at the health centre. The anemia program was designed to encourage pregnant women to come for antenatal care and get tested for anemia.
The Foundation provided funds to the facility to cover antenatal drugs for each woman, and also provided stipends for the women at every visit to support their nutrition needs. The Foundation also provided a pulse oximeter to test for anemia, attracting women because it was non-invasive. About a year into the program, the Foundation renovated the centre and equipped it with modern facilities.
"To our surprise, the pregnant women followed her"
"The first week we started the program there were 20 women. In the next two weeks we had grown to 60 women." The anemia program ran through the Primary Health Centre for almost one year. In that year, over 600 pregnant women registered for antenatal care at the facility. The Foundation posted a staff member to the facility to handle the stipend payments.
However, the GEANCO team increasingly had concerns about the programme. A grave concern was that of the 360 deliveries that took place, only 80 deliveries happened at the facility. The other deliveries were handled by TBAs. Another concerned accountability and transparency of the health centre, Chukwuka said, primarily in relation to the funds they were providing for the women's medicines.
Soon, another concern emerged.
The Officer-In-Charge (OIC) of the health centre had a disagreement with a volunteer at the centre, who happened to be a Traditional Birth Attendant (TBA). Chukwuka says, "The government employed workers would go home in the evening, and the TBA was always available to take labour, even at midnight. This made the women like her."
The In-Charge asked the TBA to leave the health centre. "She left, and to our greatest surprise, the pregnant women followed her," Chukwuka said. Christabel Anekwe, the Foundation's Clinical Supervisor, remembers the event. "When we got there the next day for the anemia control program, the number reduced drastically, from over 80 women, to 10," she said.
"We can't just leave them" -- An unusual shift to provide maternal health services
"When the program at the centre failed, we thought, 'Well, our target are the women, and we can't just leave them'," Chukwuka says, " so we reached out to the TBA who had left the centre, and we decided to continue the anemia program there." This decision opened the GEANCO team to a completely unexpected modus operandi -- training TBAs to provide quality care to pregnant women. Today they have trained 115 TBAs in Enugu State and 100 TBAs in Anambra State.
"Our passion was the women first. We needed to reach out to them," Chukwuka asserts. Skilled health workers and government officials would tell her, 'We know they exist, but why TBAs?'" she said, adding, "Some of the reasons women prefer TBAs are beyond our control; the attitude and care they receive from the TBAs. Sometimes the TBAs cook for them after delivery, or if they cannot pay they let them go."
Chukwuka says the GEANCO team trained the TBAs on hygiene, data collection, management and financial management, and to understand their limitations and know when to refer women to a primary health centre. The team developed the 'supportive supervision' system. "After the training, we ensure compliance, we attach a nurse/midwife to supervise them, and a lab technician who tests the pregnant women. We also have periodic inspections and volunteers who assist with data management," she said.
The birth of the Julia Burke Maternity Centre
During the TBA training, the poor hygiene conditions at some of the TBAs gave birth to the idea of a modular clinic. "There was a TBA who had one of the worst facilities we had seen. We wanted to change the narrative; we wanted to start with one person," Chukwuka said.
The TBA is Mrs. Anthonia Uzoigwe, fondly called Mama Ebube by her clients. By the end of 2020, the GEANCO Foundation had built their first modular maternity clinic. It was named the Julia Burke Maternity Centre, after the Julia Burke Foundation, GEANCO's funding partner for the centre. The centre is built in Enugu's Coal Camp, on land leased by the TBA with the support of the Foundation.
The modular clinic features an examination room, a delivery room, and a ward with two bed spaces, all ingeniously fitted into a shipping container with a solar panel system powering the facility and a solar fridge. The centre has a router, a phone and a headset to enable the skilled health partner to conduct telemedicine visits. The centre is impeccably clean, with a fitted canopy in front for women to sit and wait. It feels wholesome and welcoming.
The centre was officially opened in December 2020, and to date 202 pregnant women have registered there and they have had 63 deliveries at the facility, with three referrals and no deaths, according to the GEANCO Foundation. "We wanted to see how this would work," Chukwuka says, "and it is working; the partnership with skilled counterparts, data collection and management, the level of hygiene has improved remarkably. Even the pregnant women are testifying."
The team opened a second modular clinic for the TBA who was the catalyst for the initial shift in the anemia control program, at Obinagu-Nike, naming it after GEANCO Foundation Co-Founder and Board Chairman, Dr. Godwin Onyema. The Godwin Onyema Maternity Centre was opened on March 17, 2021. Chukwuka says there are plans to open three more centres in 2021, with hopes to expand to Ebonyi and Anambra states.
She confesses that getting the government on board the project is a challenge. "We know they exist, but why TBAs?" seems to be a resounding refrain, and she fears it will cause delays in their timeline for implementation. "One of the things I wish I could change is the mentality people have about these women," Chukwuka says. "I know bad things have happened at TBA homes, but I believe in change. The worst person can change with the right attitude. We can train them and help them become better."
The project has trained a total of 215 TBAs in two states, but there are presently only two existing and three planned modular clinics. TBAs have to meet GEANCO's standards for compliance. These include having a clean facility, sterilisation of implements, knowing when to refer, and being able to do the basics in terms of recording their clients' information. Given the number of TBAs that are active in the network, one concern is whether GEANCO plans to provide the same type of modular centres that these first TBAs are getting, or whether it will adapt its strategy as the numbers of TBAs who reach the required level of compliance increases.
With over 61 percent of women in Nigeria still opting to give birth outside the health facilities, the challenge of getting quality care to women during pregnancy still remains. Chukwuka acknowledges that there is still a journey ahead, but right now, she is excited at the progress that she sees at the two modular maternity centres. "We've been able to achieve this integration between the TBAs and the skilled counterparts," she says. "It doesn't really matter who does what, as long as there is a better maternal outcome... and that is what we are achieving now."