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Maternal mortality: Emergency ambulances changing narratives in rural areas

maternal mortality emergency ambulances changing narratives in rural areas

When Maryam Abdullahi’s health deteriorated, her husband carried her piggyback to the health centre in the Dange area of Sokoto State, North-west Nigeria. They travelled for miles across their inhospitable terrain to get to the facility.

“Initially, we thought it was the normal pregnancy dizziness and pulling sensations,” she recounts.

“The situation worsened with severe abdominal pain and difficulty in breathing. We can hardly get a vehicle in this hard-to-reach area, and my husband had to carry me on his back to reach a health facility. That was about five years ago.”

Malam Musa Abdullahi resorted to backing his wife because that was the only option available to him at the material time.

“We used donkeys, camels, and motorcycles. If there is no donkey, no camel or motorcycles, we back the patients,” he discloses.

Still flashing back to the experience, Aisha relates: “I thought I was going to die but thank God I survived that unpalatable incident.”

But many rural women never make it when they face precarious health conditions.

“I lost a sister, Zainab, who was being transported on a donkey. By the time they got to the hospital, she was already dead,” Maryam recalls as she gives a despairing sigh, gloomy at the memory.


Solving the access problem

ACCESS to emergency care for pregnant women is often an immense challenge in rural areas where the transport dilemma contributes to poor health indicators and high mortality rates. Also, cultural and socio-economic factors related to delay in seeking care compounds the problem for many rural women who lack autonomy of decision-making and local support, thus increasing the risk of maternal mortality.

A 10 -year review of maternal mortality in Sokoto by Obstetrics and Gynaecology consultants LR Audu and Bisallah Ekele points out “most of the deaths could have been prevented with prenatal care and prompt treatment of the obstetric emergencies.”

Maternal mortality is not a concern in Sokoto State alone. It is a global concern and a target of the United Nations Sustainable Development Goal (SDGs) 3, aiming to cut the deaths. The targets include reducing the global maternal mortality ratio to less than 70 per 100 000 live births and ending preventable deaths of new-born and children under five years of age by 2030.

According to the World Health Organisation (WHO), 94 per cent of all maternal deaths occur in low and lower-middle-income countries. The organisation adds that poor women in remote areas are less likely to receive adequate health care, noting poverty, distance to facilities, lack of information, poor quality serviced, cultural beliefs and practices as main factors that prevent women from receiving or seeking care pregnancy and childbirth.

In 2018, Governor Aminu Tambuwal -led administration introduced specialised ambulance services to deepen access to medical care and improve emergency service delivery across the 23 local government areas of the state.

The state government’s initiative was to ensure emergency response at the grassroots and patients transfer when the need arises.

“We have about 300 ambulances in the state. In each political ward, we have one; in the General hospitals, we also have one each, “says Malam Usman Bello, State Coordinator, Ambulance and Referral Services Sokoto.

For the 244 wards in the state, the state government handed the ambulances to each community with a committee in charge. The committee comprises the village head as the chair, while the secretary is the officer-in-charge of the primary health care centre. They station the ambulance within the primary health centre with an emergency number. If any problem, affected persons can call, and the officer in charge sends the ambulance.

In some localities, they equipped community groups with mobile recharge cards to inform relevant persons, including the ambulance drivers, when the needs arise. Such groups also partner with the National Union of Road Transport Workers (NURTW) in transporting patients in some hard-to-reach areas.

Committee members contribute to maintaining the vehicle, such as servicing, fuelling and buying tyres. However, where there is substantial damage to the vehicle beyond the community’s capacity, the government takes over the repairs.

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How the ambulance services have been adopted across Sokoto State
FIELD trips to various wards across all zones of Sokoto gave a picture of the initiative’s impact on maternal health.

Malama Hauwa of Rakwame village, Rabah local government area in Sokoto-East zone used the ambulance services. “The gesture has been improving the lives of locals, particularly pregnant women who suffered untold hardships previously. They conveyed me in the ambulance to Gandi when I was ill,” she recalls.

“I was pleased it was available; otherwise, it would have taken a great deal of time and effort to get a means of transportation.”

Hauwa observes that more women are accessing hospitals with emergency vehicle than before because they have eased transportation and care.

In the southern zone of the state, Aisha Bello and Rabi’atu Abubakar of Gumainiya village, a suburb of Tureta local government area, about 33 kilometres to Sokoto city, said they benefited from ambulance services at different times, describing the initiative as succour to women in the area. “About nine in 10 of ambulance services users are women who faced difficulties during child delivery and other health conditions,” Aisha observes.

Likewise, in Bodinga, Sokoto South district, Village Head of Sifawa, the Ward Development Chair (WDC) Alhaji Yusuf Sarkin Kudu, Ubandoman Sifawa, says previously they sought private vehicles and motorcycles’ services to transport patients to clinics in times of emergency. He stressed that people faced untold hardships before the ambulance.

“The ambulance has contributed immensely to healthcare activities across the area,” he notes. “It reduced cases of deaths because, in the past, we received many reports of patients dying on transit or unable to get a means of transportation to healthcare facilities.”

Malam Arzika Aliyu, the Ambulance Driver of Gagi Primary Health Care Centre in Sokoto North senatorial zone, speaks about his work with great energy and enthusiasm. “I transport patients from Tsaki, Gagalawa, Durbawa and others on daily bases,” he says. “I am woken up at all the times as the community leaders, hospital workers, and I receive distress calls about patients in need of the service. I take patients to Gagi PHC and sometimes to the Specialist Hospital in
Sokoto, the state capital.”

He recalls a peculiar situation when he took a pregnant woman who was in very severe health conditions. “I conveyed her from a remote area near the popular Durbawa area, about 8km from Gagi. She was in a very pathetic state. Thank God when we got to the clinic, and she received attention, she responded to treatment, recuperated and regained her health.”

Conversely, he recounts a sad incident that is still vivid in his memory. “On this fateful day, I took a pregnant woman from Gagalawa. She had lost excessive blood and needed a transfusion because she was in labour for too long at home before they sought medical care,” he narrates. “On our way, she died, and we returned to the villages for burial.”

The driver frowns on how people leave patients in difficult situations at home without calling for attention until the condition worsens. Aliyu lauds the District Head of Gagi and Chair Ward Development Committee’s efforts in ensuring vehicle maintenance and his upkeep.

He, however, laments that one of his challenges is the lack of a motorcycle to transport himself to the clinic where the ambulance is stationed, just as some other ambulances’ drivers, voice out their desire for salary increment. They note that a monthly salary of N18,000 is inadequate. “We are always at alert 24 hours, and we have families to cater for. We would be grateful if we have an increase in the salary,” one of them makes a plea.

Improvements to important health care metrics
DISTRICT Head of Gagi, Alhaji Sani Umar Jabi, underscores the ambulance’s positive impact on his community. “The vehicle has helped avert infant and maternal mortality; it has helped to address postpartum haemorrhage in the Gagi area of Sokoto, “he says.

The traditional leader states that before the ambulance in Gagi, hospital delivery was about five per cent in a month, but with the ambulance’s service, it has grown to about 70-80 per cent per month.

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“Hitherto, you see a lot of maternal issues and maternal mortality very frequently, but now hardly do you hear any death related to maternal deaths because there is more awareness of ambulance use.”

“Today maternal mortality is becoming history in my community and even environs; we have not been hearing of maternal mortality related to child mortality, maternal mortality, women are healthier now, the children are also healthy.”

It was a similar experience in the Kware local government area, in the central part of the State where Hajiya Aisha Bello, the health educator in the locality, observes that the emergency vehicle is enhancing rural women’s lives and maternal health.

“It boosts attendance at antenatal clinics and delivery at the health facility in their localities. If there are complications, the health personnel give them referral from there to a higher level.”

She notes it has made the community take ownership of the communal activities because they take care of the vehicle.

“When there was no ambulance, the men used to say everything about maternal health is a women’s affair, but now they take it as their own. They want nothing to affect the ambulance. They always maintain it and take care of it. The ambulance is important to the community.”

The number of women coming for ANC has doubled with the ambulance, from about 40 percent to 80-90 percent, she points out.

Hajiya Aisha adds that with an awareness campaign on state and development partners’ interventions, the locals now appreciate the importance of hospital delivery.

In Bodinga local government, the Director of Health, Bello Maidamma, also speaks to healthcare delivery improvement.

He harks back to when there was no health facility close to the people and the transportation challenges.

“So many women were dying. You won’t even know their number. Some pregnant women had to use donkeys where there is no road,” he recalls.

“Now, we have a lot of improvements -health facilities, roads and ambulances in all wards for easy access, that is why maternal mortality has reduced.”

Sixty per cent of the women that will deliver in the communities use the ambulance, according to Abdullahi Hassan, the health educator of the Gwadabawa local government, in the eastern zone of the state.

“Before pregnant women suffer from their locations to the health facility. Previously they used a donkey; some deliver at home. Before, only 10 per cent come to the hospital, but now when a pregnant woman has a problem, they call the ambulance driver,” he states.

“It has made them use the hospital. We told the Ward Development Committee (WDC) to mobilise their people, each month, we meet with them, sensitising them on allowing their wives to use the hospital for delivery.”

Still in the Sokoto East zone, about 100 km from Sokoto city is Ilela, which shares a border with the Niger Republic to the north.

Deputy Director of Health, the Ilela local government area, Abdullahi Gidan Hamma, affirms that the emergency ambulance facilitates access to emergency obstetric care and changes mindsets of the rural populace in accessing health care services.

“Before then, the men were ignorant of the health issues, but the ambulance makes them value health services. Because they are among voluntary organisations in their communities, contributing to the maintenance of the ambulance,” he elucidates.

“They get insight on health activities and thus allow their women to go to hospitals. In these facilities, we conduct routine immunisation, nutrition services, ANC services. The ambulance increased our facility patronage.”

He says the maternal death toll has plummeted from 20 per cent to less than three per cent while hospital attendance tripled.

Safiya Abubakar’s husband was one of those who stuck to the local way of treatment. But with the emergency ambulance, he saw how it was coming to the rescue of women who needed it. “He now encourages me to visit the health facility if the situation warrants,” the wife tells this writer.

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Mallam Sidiq Faruq, a business owner who travels often, confirms: “I have told my pregnant wife that even if I am not around if she feels unwell, she should just go to the hospital.”

“I even spoke with the officer -in charge of the primary healthcare centre that my wife may come even if they do not have the drugs, he should buy it, I will pay when I come back.”

Muhammad Sahabi Dange, the Director of Primary Healthcare in the Wamakko local government area, discloses that some men didn’t allow their wives to go to the hospital because they do not have money for transportation.

“Because they know there is a vehicle now, they allow their women. The emergency ambulance has added to hospital attendance very well. Many come to the hospital; they feel that even if they don’t have money, the vehicle will get them to the hospital.” He adds: “Hitherto, antenatal care here attracts 20-30 women, now because of the ambulance services and the mobilisation, we have over 200 women. “

Issues with the programme’s adoption
However, despite the glowing depiction, some under challenging terrains cannot utilise the ambulance. Some locations are gully erosion and riverine areas. In parts of the state, they cannot use the vehicle to convey the patients because of the security challenge.

The State Coordinator confirms that they have recalled the ambulances from the wards to the local government headquarters in such areas, including Rabah, Wurno, Goronyo, Tureta, Tangaza, Binji, Isa, and Sabon Birni.

Speaking on this challenge, Malam Idris Ibrahim, the Health Educator of Tureta local government area, expresses concern that despite the positive impact in reducing maternal deaths by more than half of previous incidents and improved access to hospitals, activities of bandits have been affecting ambulance services in the area. He laments the ambulance could not access many parts of Tureta for fear of attacks.

In some communities, the ambulances are in sorry states, lying fallow at the local government headquarters.

Investigations reveal some Ward Development Committees can better manage their ambulances than others, as some wards have more influential people who will support or render selfless service. There were also cases of some ambulances being diverted to other uses, such as carrying firewood and other things.

Some inhabitants lament the delay in fixing an ambulance when it develops a major fault.

One villager, Abubakar Ahmad, comments: “The ambulance scheme has improved the people’s health. As an emergency initiative, any fault with an ambulance should be given an emergency response. The government should provide maintenance funds and other logistic support.”

Hajiya Halima Sani, a maternal health advocate, shares her thoughts. “It is laudable that Sokoto has this service, which is contributing to the Sustainable Development Goal, (SDG) 3 aimed at plummeting the global maternal mortality rate,” she states. “Still, it is vital to deploy strategies to ensure more women in difficult terrain and hard-to-reach areas get a prompt response to obstetric emergencies.”

Some recommend four-wheel-drive ambulances that can access more landscapes to reach the unreached and enhance grassroots’ access to healthcare services.

However, Mallam Bello, appointed as state coordinator Ambulances and Referral services last year, asserts that the state government started his office to manage the ambulance better. Some drivers were using the vehicle for commercial and other purposes not meant for.

“We had the serious issue of mishandling the ambulance in the state. Before my appointment, you could see an ambulance carrying everything inside. Now we are in control. When you see an ambulance, it is for health emergencies.” He also revealed plans to make a full garage specifically for the ambulances’ maintenance to reduce the communities’ burden.

The coordinator added that Sokoto is working with development partners such as Plan International and Integrated Health Program (IHP) to boost ambulance services, such as creating Closed User Groups and training ambulance drivers.

*This story was produced with the support of a reporting grant from
Maternal Figures and Code for Africa.

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