Mariama was in trouble. Alone in her hut in a remote village in southern Senegal, she had managed to successfully deliver her baby boy. But something was wrong. Mariama’s labor pains continued, agonizingly painful, and there was blood everywhere. Like virtually all of the women in Dialadian, Mariama had had no prenatal care. She didn’t know that she was carrying twins, and that the second baby was transverse – lying horizontally across her womb.
By an incredible stroke of luck, a young doctor was in the village that day meeting with the elders. Dr. Ibrahim Aw, a soft-spoken, earnest and energetic physician is the regional director of WIN, a pilot project to provide mobile health units that now travel regularly to villages throughout the region. WIN was launched by Senegalese NGO ADEMAS and Population Services International (PSI) out of Washington, DC in 2015. I have been working closely with both ADEMAS and PSI over the past few years as both an investor and partner in this initiative.
Staffed with a midwife and a nurse, the WIN units provide ante- and post-natal care, monitor infants’ health, and give women reliable access to contraceptive products. At the same time, recognizing that the World Health Organization’s research has indicated that professionally assisted delivery improves outcomes for both mother and child, the project hopes to increase the number of women delivering at local health centers.
On the day of Mariama’s crisis, the arrival of the first mobile health unit to Dialadian was still several weeks away. Dr. Aw was assembling his team and ordering medications and equipment. He also knew he needed to prepare the way with local stakeholders. He had come to Dialadian that afternoon as part of his outreach to introduce the project and discuss logistics. Dr. Aw was pulled from his meeting with the elders; he grabbed his medical bag and was directed to Mariama’s hut. He stabilized her and then transported her in his vehicle to the nearest health facility, racing across the dirt roads. Mariama survived the ordeal, though sadly, the second child did not.
When I met Mariama in Dialadian, she expressed her gratitude to Dr. Aw for saving her life, and for the WIN mobile units that now come to the village offering maternal and infant health care. Later, I asked Dr. Aw about the day he rescued Mariama. He shook his head somberly, recalling the grim situation he encountered in her hut. That day underlined the dire need for a project to improve antenatal care in the region, and reinforced the WIN team’s sense of urgency to launch the WIN project as soon as possible.
Mariama describes her traumatic experience of giving birth alone to twins in her hut.
But despite the enthusiastic reception in the villages and the undeniable achievement of bringing badly needed services to a remote region, the WIN project has faced challenges trying to translate the success of the mobile clinics into increased numbers of local women giving birth in health centers. To understand the situation, ADEMAS’ Senegalese staffers went into the villages to interview both women who had given birth at home and those that had done so at a health facility. As anticipated, the women emphasized the transportation challenges they face trying get to local health centers: options are often limited to a motorbike or a donkey cart, and can be expensive for many families.
But more barriers than just the lack of reliable transport soon became clear. For instance, at a health center, a small cinder-block building, a woman will not have a private room, and she will not be cared for by her family. She will labor in hearing range of everyone else in the health hut. In a small community, everyone will know everything. This is not a small thing in a proud society. There is also the culturally serious matter of the handling of the placenta, which must not be handled by a stranger and must be buried correctly to protect a woman’s future fertility and to help heal her womb.
Her other choice is to stay in her own hut looked after by a close relative, likely her mother-in-law, who will tend to her and carefully protect her privacy. She will not have to travel on a cart or motorbike, and no money will be spent from the family’s meager funds. But if any complications arise -- as they did in Mariama’s case -- she can only pray for her own and her child’s survival.
Before the arrival of WIN, a woman in these villages did not know that it is safer for her and her baby if she delivers in a health facility. She did know, however, that very few women in her village go to the health post to deliver. So the challenge for WIN is not just to deliver antenatal care but also to develop solutions that address all the concerns, both practical and cultural, of the mothers that the project treats. These solutions must include:
Creative Transportation Solutions: Ambulances have been tried, but gasoline is scarce and a lack of available maintenance has shown them to be, for now, unsustainable. A tuk-tuk taxi (part vehicle, part-motorbike) was considered and discussed throughout the region, but, as with the ambulances, there were concerns about the communities’ ability to maintain and manage the vehicles. Instead, every driver with a motorbike has been registered, and is paid for every trip he makes to transport a pregnant woman to deliver in a health center. In addition to monetary compensation, a public acknowledgement plan to honor drivers is under development. It is not an optimal mode of transport for a woman in labor, but it is a start.
Collaboration with Government Health Centers: WIN staff are seeking to coordinate with the Senegalese Health Ministry, to share our experience and the results of our village interviews. Together we hope to work with other aid groups that have grants to improve the design and practices of the government health facilities in the region, to address the concerns of local mothers.
Integration with Cultural Norms: The WIN project seeks to leverage the expertise of ADEMAS and PSI in effecting behavior change by working within the village and regional communities. Through local women’s groups, influential community leaders, and involving other local stakeholders, the project has already begun to change attitudes towards provider-assisted births, but recognizes that this is a long process.
The WIN project illustrates that to bring true, sustainable change requires a multi-faceted, evidence-based approach. It shows how important it is to consider the needs and motivations of the women we serve, and to view potential solutions through their cultural lens. While the story of Mariama’s rescue is uplifting, it also puts into perspective how much effort it will take to understand how to save the lives of the neediest women and their infants.
Celebration of life: Mariama gives me her baby to hold.