The article was originally posted on the International Confederation of Midwives (ICM) Newsletter. Reposted with permission.

Photo credit: Wellbeing Foundation Africa

Every pregnancy is unique. Every delivery is unique. Every child is unique. This awareness is commonplace amongst midwives across the world who work to empower and educate pregnant women and babies, and to one another as healthcare providers and advocates for reproductive and maternal health. In the context of the Wellbeing Foundation Africa’s (WBFA) MamaCare Midwifery team – comprised of Mrs Patricia Komolafe, Rita Momoh and Eunice Akhigbe – this empowerment is at the core of their roles.

Based in Nigeria, the MamaCare midwives are a unified trio with complementing strengths – a sisterhood of solidarity who support one another in their shared service of women and newborns. With a longstanding career behind her, Mrs Komolafe is the ‘older sister’ figure, confident from her ample experience. Rita is resourceful; dynamic – always available to empower and inspire the pregnant women who see her as a gust in the sails and a source of knowledge; while Eunice completes the team by providing personalised care at an individual level, with a youthful curiosity in her work that embodies the very spirit of working within a midwifery family.

The MamaCare midwives work with a consistent mindset dedicated to a simple ethos: providing antenatal education to pregnant mothers, as well as well as serving the wider communities. Their ambition is to reduce maternal and newborn mortality indices across Nigeria, and education is their tool to achieve it.

“Midwifery teaching is as practical as it is about theory,” says Eunice, “We use mannequins and even sometimes our own bodies to demonstrate key danger signals during pregnancy.”

Through their classes, these midwives teach groups of pregnant women and maintain consistent contact for any queries or behavioural doubts they might have. At any given time, the online groups these midwives host can contain up to 250 active members. Still, the MamaCare midwives face a variety of obstacles – ranging from limited access to key resources to undervaluation of their socioeconomic contribution to the community. There is a global call for investment in the midwifery workforce that is based on a significant body of compelling evidence that this is one of the most cost-effective ways to improve sexual, reproductive, maternal and new-born health outcomes. However, the strategic opportunity midwifery represents for government investment is often neglected, and consequently, midwives are not valued commensurate to their work. Rita is very much aware of this in daily work, where even a moderately greater provision of information could make a positive impact in the community.

Photo credit: Wellbeing Foundation Africa

For the MamaCare midwives, so much comes back to Water, Sanitation and Hygiene (WASH). WASH is a key element in preventing the effective and healthy provision of services from midwives to pregnant mothers in healthcare facilities. However, there are a number of hindrances to making WASH ubiquitous.

“When there is a spread of disease such as dysentery, Lassa fever or Ebola, the outbreak could be stopped at the source with preventive lessons on hand-washing and hand-washing stations,” says Rita, “Still, most times basic infections such as diarrhoea will spread in hospitals due to a lack of a good water source and recognition of what midwives bring to the table.”

She cites the inherent difficulties in her day-to-day work: lack of basic resources such as running tap water from a safe source, clinical tools such as forceps, gloves and syringes as well as a systemic entrenchment of unfair practices. These practices place midwives in the unenviable position of requiring patients to fund their own supplies and provide basic items to facilitate a midwife’s care. This is the standard of primary health service delivery across Nigeria, where only 31 percent of public health care facilities have access to a basic, functioning hand hygiene station.¹ However, it is one that midwives enforce with great reluctance. Barriers such as these hinder the MamaCare midwives’ work despite having the incentive, knowledge and volition to help mothers and newborns with whatever resources are available.

“We need running taps in rural and even urban areas,” says Eunice, “More enlightenment on hygiene and sanitation needs to be pursued. What we need the most are the basic resources and increased capacity for service distribution, as some of our classes can gather up to 200 pregnant women at a time.”

Photo credit: Wellbeing Foundation Africa

With such overwhelming demand for midwifery access, the three midwives have to be strategic in how they engage with the community. Data collection is recognised as vitally important, and so they serve a multifaceted role: educators, caregivers and researchers.

“We will firstly register these women and have them undertake key laboratory tests to monitor their health progress,” says Eunice, “As we don’t have the capacity to cover healthcare facilities more frequently, we can only check on the test results and progress once a fortnight.”

Because women in Nigeria have such diverse needs and priorities, WBFA midwives have adopted a holistic approach to MamaCare classes. Subjects range from Malaria, HIV or hepatitis in pregnancy, personal hygiene, environmental hygiene, food safety and beyond. Many of these topics are either new or relatively unexplored – even taboo – to many of the women attending. This requires a nuanced approach: both sensitive to subtle shifts in attitude, but delivery of appropriate information in a manner that is assertive and informative. Eunice’s educational style is focused on building interpersonal relationships with each of the pregnant women in her classes.

“When I am speaking at a class and am covering a topic that is taboo, I will take in the facial expressions and mannerisms of the pregnant women to understand how they are responding to the lesson,” she says, “When I notice that attendees are shy or preoccupied approaching a topic, I will see them fidgeting or whispering to their colleagues. Once the community class is over, I will meet that person and see if they wish to share any queries they may have. Midwives should provide this safe space where the rest of the community cannot.”

Building trust is a key element of midwifery practise worldwide. Therefore, while catering for individual needs, a sense of community must be built through effective regulatory frameworks and strategies as well as an open platform for communication. This is where the veteran midwifery profile of Mrs Komolafe – affectionally known as “Mrs K” – proves to be the glue in the fabric of the MamaCare family. Operating with diligent, transparent oversight in her work, Mrs K is a maternal figure to mothers and midwives alike. Having joined WBFA in 2015, the antenatal to postnatal classes she has led have ranged in settings: from police stations and military bases to general hospitals and working with a variety of partners.

“Getting around to all the places we work in can prove difficult. What we urgently is greater access to these women, in terms of developing the capacity to provide midwifery services across facilities,” Mrs K explains, “We have covered, since 2015, 7 local government areas across Kwara state and are looking to expand the family of communities we cover in months to come.”

The midwives unanimously agree that despite the hindrances in their work, the opportunity to play diverse roles in their practise make even the most challenging situations rewarding and valuable. Their deep solidarity with the women they support mobilises them as community engagers, where they create a familial sense amongst groups of pregnant women and a culture of community and transparency. Their work underscores the often misunderstood role that midwives play as leaders and team players, educators and motivators, professionals and, perhaps most importantly for communities, family. It is particularly in rural areas such as those across Kwara state where Patricia, Eunice and Rita work, where reproductive and maternal health information is not readily available, that the impact of their work is ever-more worthwhile.

1 World Bank, 2017.