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An effective strategy in Foron
Introducing Fiona Jara: I am a missionary from Australia volunteering my services in West Africa (and am currently raising support to work as a volunteer in Tanzania) in order to see a reduction in the high maternal and infant mortality rates and women within the communities empowered. By working in partnership with existing organizations, and with the whole community, I am hoping to have a greater impact on birthing outcomes. I am an Australian Registered Nurse/Midwife with a Masters in cross-cultural communication, and am also registered as a Nurse/Midwife in Nigeria. I am married and have 4 daughters, two of which were born in birthing centers, one in a hospital in Nigeria, and our fourth daughter was born in a hospital in Australia.
Fiona’s work in Nigeria…
In 2006, COCIN (Church of Christ in Nigeria) wrote a letter of invitation for me to assist the church in their efforts in maternal and child health. In 2007, our family moved to Nigeria and commenced working with COCIN Community Development Program (CCDP), based in Gindiri. During this first year I attended a CHE training to become a Trainer of Trainers and built up relationships with those who were already implementing CHE. I spent the first few years surveying the current health situation and needs of the communities. From the information gained from this I started applying strategies for assisting the health professionals as well as the communities. I designed the health booklet (which was to guide health professionals in their care of pregnancy, birth and baby care), held workshops and women’s meetings, and started facilitating CHE seminars. After moving to Jos in 2009 (so that our children could attend Hillcrest School) I continued with the CHE seminars and was advised to commence implementing the booklet at Vom Christian Hospital (VCH), which I did 2 days a week while also teaching at the government School of Midwifery and carrying a pregnancy. During this time I also underwent training to be a Master Trainer for Home Based Life Saving Skills (HBLSS).
Whilst heavily pregnant I joined an international forum for health professionals working in developing countries to reduce maternal mortality (Maternal Health Task Force). During this time Dr Nanle (the Director of COCIN Health Department) shared with me the need to survey the community to find out why 70% of women in the Plateau still give birth at home and to find a strategy to address this. I decided to write out ideas for assisting the health system to address maternal health, many of which came from the forum. A women-friendly birth centre was one idea. I shared these ideas with Dr Nanle and we concluded that there is a need for education of the community (to prevent morbidity and mortality rates) as well as the health professionals (to help them provide quality, up-to-date care).
I decided that a good strategy would be to combine the community programs (using CHE and HBLSS) with medical workshops focused on ‘Woman-Friendly’ birthing care. During this time I was also fulfilling Nigeria’s requirements to become registered to practice as a nurse/midwife in Nigeria. I successfully sat the exams and interview in Lagos and did my 3 month placement at VCH and Jos University Training Hospital (JUTH), which also gave me good insight and contacts.
Whilst at JUTH I met Lucy Pam who told me about the women’s health needs in the Ghuwes and Bwarra communities in Foron. These communities recognized the needs of their women and children and initiated contact with Lucy Pam, asking for help and for something to be initiated in their community. They were very eager for community education programs to be held among their people and are willing to be involved. This makes it an ideal community to start a new project. Lucy asked if I would be interested in assisting her with a birthing centre and community programs in Foron. I explained to Lucy that I am not an NGO but that I could help train her and the community in applying effective strategies. We started by surveying the community to find out their attitudes and opinions, maternal and infant statistics, and current healthcare situation. We did this (after meeting with the village elders) by surveying the community members (both male and female) and the health facilities in the area. Lucy and I also met with the COCIN Pastor for Foron and the Chairman for Barkin Ladi LGA to share with them why we were surveying the community.
The strategy in Foron:
In response to the surveys we planned ona multifaceted approach to reducing the maternal and infant mortality and morbidity rates in Foron. As with many communities in Plateau State, most of the births in Ghuwes occur at home. The women were either unwilling or unable to attend a health facility for their births thus the risk of complications were arising from traditional beliefs and practices, lack of access to professional care, poor sanitation, and poverty. There also appears to be a lack of trust in the current healthcare system. To address these issues we implemented:

  1. A ‘Women Friendly Birthing Centre’ (WFBC – an outpost) within the center of the community which will focus on safe natural birthing techniques, providing women with respect, good education and informed choices of care in a homely environment. It accommodated for the woman’s birthing style and desired support network (like at home) but in a safe environment. The women had a say in how it was decorated and furnished to help them feel comfortable and attracted to utilize the place. The outpost was equipped to attend to uncomplicated pregnancies and births and refers women to the clinics where appropriate. The staff were trained in natural birthing techniques and care appropriate for a birthing centre (and encouraged to liaise with the clinics). This training was also extended to the staff in the surrounding clinics to promote unity and continuity of care.

  2. Community education programs were implemented in the village to help members recognize and respond appropriately to illnesses and health complications, especially in relation to pregnancy and childbirth. The programs help the community to address their felt needs, and prevent disease and suffering in a wholistic manner. We did this through the use of two tools: Home Based Life Saving Skills (HBLSS) and Community Health Education (CHE).

  3. Antenatal classes/advocacy groups were encouraged as part of the community health programs. These are gatherings where women can share their experiences and fears, expectations and questions with the group while hearing about, seeing and applying principles of care relating to pregnancy, childbirth and family health. These meetings can double as advocacy groups which give feedback to the health post and clinics. Principles on how to effectively run such classes were offered to the WFBC staff as well as the clinics. (So far, the women of the Training Team have been trained in how to hold such classes, but didn’t see it being applied before I left! Much of this can also be achieved through the growth groups that are established as part of the CHE program)       

  4. Workshops and trainings for health professionals will be held by Midwife/Community Health lecturers on areas of need and up-to-date practices. I held workshops on how to handle complications of birth. The clinics were encouraged to be involved in the project and be informed of the stages of development so as to best serve the community.

How were these programs implemented?

  1. The Women Friendly Birthing Centre (outpost):

  • The community offered three volunteer staff that will run the centre. They were trained in an initial 2 week training program on the principles of WFBC care, and then will be intermittently updated on latest practices and workshops as needed.

  • The community offered a temporary building (which they renovated for this purpose) as well as land to build a permanent centre.

  • The community funded the setting up and equipping of the centre by holding a community fare/fundraiser.

  • Staff from the clinics in the area (from COCIN, govt PHC, and Bukata private) were also trained in the principles of WFBC care for the purpose of unity and continuity of care within the community. They may choose to incorporate these principles in their services. Updates and workshops will also be offered to the staff.

  • Both the WFBC and the COCIN clinic were encouraged to utilize the Health Record Booklet for their paperwork.

 2. Home Based Life Saving Skills Community Education Program:
By agreeing on appropriate interventions, and demonstrating them through role plays, HBLSS teaches communities what actions to take at home and how to safely get the sick to a clinic in time for further professional treatment. 

  • Is a family and community focused, competency based, participatory program which focuses on prevention, safe birthing, first aid and referral.

  • It recruits and prepares the whole community as stakeholders, involving them as decision makers, and uses pictorials to explain their roles in life-saving strategies. It is evidence based, culturally sensitive, and works in conjunction with the health facilities.

  • Before I left I trained the Training Team as Lead Trainers in HBLSS and held a brief workshop on explaining HBLSS for the clinics in and around Foron.

 3. Community Health Evangelism education program:
CHE is a wholistic tool which helps the community to identify and address their own needs rather than relying on outside relief. It addresses all aspects of health including the physical, emotional, social, spiritual and environmental. It requires the training of volunteers who will do home visits with physical and spiritual teachings (focusing on disease prevention) as well as facilitate community projects (such as digging toilets, and building a centre). The end result is that communities and individual lives are transformed.

  • A Training Team is formed – a group of 4-6 facilitators that have been trained to train

  • They train the community committee - who are selected by the community to represent the people and oversee the work.

  • Then train the CHE’s – volunteers who do the house to house teachings.

The HBLSS and CHE programs have been combined into a training program called ‘BLISS’ which we used to better utilize the volunteers and reduce the amount of work and confusion it may cause in the community. This tool has now also been incorporated into the Women’s Cycle of Life (WCL) training materials, which is a specialized arm of CHE which focuses on women’s issues.
Objectives of the project (over 2-5 years):

  1. To increase the percentage of births (in Ghuwes and Bwarra) delivered in a health facility by 50%.  I was informed that many women are now using the WFBC or clinic.

  2. To reduce the maternal and infant mortality rates (in these communities) by 20%. A repeat survey (2 years later) showed that maternal mortality rates dropped from 36% to 0%, and only one baby (within one month of age) has died compared to 63% previously.

  3. To improve the relationship between the clinics and the community and their united efforts for improving their health and the wellbeing of the community. Many issues have been addressed including prevention of malaria and typhoid, hygiene and sanitation.

  • Information has been difficult to collect due to civil unrest in the area. The last I heard my main contact and person involved in these programs (Lucy Pam) moved away due to the violence.

Many of Nigerian clinics current practices are outdated and unsafe as well as unnecessarily unpleasant for the woman. The result is a lack of trust by the community in the health facilities. By making the WFBC well proximated, culturally and woman sensitive and clinics better equipped in principles of care it has attracted women to birth in these venues - which is safer than birthing at home. By encouraging community involvement in education programs the women have been empowered to give better preventative care for themselves and their families. Together, these strategies have proven effective in improving safe outcomes for motherhood. Hopefully, despite the shortened life of this program, the Training Team (and community leaders) will see how effective these tools can be and will duplicate these strategies into other communities.
Due to the great success we saw in Foron we have now been asked to join a team in Tanzania to train leaders there (especially health professionals) how to apply similar strategies to their communities. We are currently home in Australia whilst we seek financial support to do this work. If you are interested in supporting us or learning more about this work you can contact Fiona on or through ‘BetterCareTogether’.