In Mendy Kunda, a remote village within The Gambia’s North Bank Region, accessing a hospital during labor often hinges on the swift availability of assistance. Rose Mendy, a local resident, has relied on her community for support, including a traditional birth attendant (TBA) who assists women during the critical hours before reaching medical care. This village-based aid has been key for Rose and others facing childbirth challenges in areas with limited healthcare access.
Rose’s experience with childbirth has taught her the importance of prompt medical attention. During her first pregnancy, she gave birth at home unexpectedly, but with her second pregnancy, she was able to recognize the signs of labor and deliver safely at Essau District Hospital. She credits the traditional birth attendant in her village for providing vital support, saying, “The TBA in our village is always there to help whenever a pregnant woman is about to give birth.”
Rose’s current pregnancy has been marked by unfamiliar illnesses and painful stomach aches, highlighting the need for timely medical care. While her husband often helps transport pregnant women to the hospital, his absence can create challenges. In such situations, community-based support, including traditional birth attendants who can identify danger signs and connect women to formal healthcare services, can be key in ensuring women receive the care they need.
A Regional Crisis Meets Local Solutions
For generations, childbirth in many rural communities across West Africa has carried significant risks, partly due to weak healthcare systems. Fortunately, in places like Mendy Kunda and Nigeria’s Jigawa State, public-private partnerships, community-led interventions, and innovative policy reforms are integrating TBAs into the formal healthcare system, subsidising emergency transportation, and strengthening grassroots health networks.
Studies show that 75% of Gambian women cite insufficient time for travel and 29% blame transport difficulties as the major reasons they avoid health-facility births. Although 83% want a medical professional present, more than 70% end up with a TBA, even though only 27% plan a home delivery. A similar paradox exists in Nigeria, where most pregnant women attend antenatal care and intend to use a hospital, but end up delivering at home or with a TBA. In two studies conducted in Southeastern Nigeria and Nasarawa State, 82.2% of pregnant women surveyed chose and planned for a hospital delivery, but 59% of them delivered at home or outside a health facility.
Rather than demonising the use of TBAs, local health systems are increasingly recognising their role and integrating them into formal healthcare structures. Through training, retraining, and the provision of essential equipment, TBAs are being supported to carry out safer pregnancies and childbirth while strengthening links between communities and formal health facilities.
Veronic Mendy, a local TBA in Mendy Kunda, noted that past challenges involved women hiding labour pains to deliver at home without medical help. “To tackle this issue, we now make it a priority to accompany pregnant women to the hospital promptly. While there, medical staff teach us what to do in case of an unexpected home birth.”
Hafsat Shehu, a trained TBA assigned to the Madobi Primary Health Care (PHC) Centre in Jigawa, shared that, “Before the training, no matter how far away the pregnant women are, I travel on motorcycles to deliver babies at home.” Today, Hafsat acts as a community bridge. Instead of attempting risky home deliveries, she screens women, urges them to visit PHCs for routine antenatal care, and immediately initiates referrals if obstructed labour occurs.
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Transportation Solutions in Action
To address the transportation barrier, Jigawa State introduced the Jigawa State Maternal and Neonatal Emergency Transport Scheme. When a woman goes into labour, her husband contacts a local community health ambassador, known locally as Jakada Lafiya, who maintains a direct directory of vetted local drivers. The driver transports the patient to the nearest PHC at an agreed fee, which is subsidised and directly reimbursed by the state. Recently, according to Dr Shehu Sambo, the Executive Secretary of the Jigawa State Primary Health Care Development Agency (JSPHCDA), Governor Malam Umar Namadi doubled the drivers’ per-trip stipend from ₦5,000 to ₦10,000 to ensure drivers remain motivated.
Samuel Chaw, the Village Development Committee Chair, emphasises similar local progress in The Gambia. “We’ve appointed women leaders as TBAs, and they do an incredible job regularly checking in on expectant mothers,” Samuel noted. However, referrals remain difficult, often requiring Chaw to walk to a nearby village for a taxi. Fortunately, supportive local drivers and villagers frequently assist with emergency transport free of charge. The VDC also organises educational forums on proper nutrition and encourages husbands to ease their wives’ household workloads.
Measurable changes are on the ground. The Gambia has seen a significant drop in home deliveries, with rates plunging from 36.18% in 2013 to 14.39% in the latest Demographic and Health Survey. The Gambia’s Health Ministry is building on this momentum through the National Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) Policy, thereby reinforcing mortality monitoring at the central, regional, facility, and community levels.
In Jigawa State, Nigeria, the impact is equally commendable. According to Dr Sambo, the transport scheme safely transports over 3,000 women annually, and participating facilities have recorded zero maternal mortality linked to transport delays since its inception. This collaboration has transformed clinic attendance. Ahmad Yakubu Kwaimawa, Officer in Charge at the Jaudi PHC, noted a sharp increase in facility utilisation. “We used to have between 20 and 30 deliveries in a month,” Kwaimawa explained.
Limitations and Institutional Gaps
Despite these inspiring achievements, significant challenges remain. Institutional gaps still threaten the long-term sustainability of these models. Some TBAs occasionally delay referrals, and the occasional nonchalant attitude of Skilled Birth Assistants at clinics can alienate patients.
Furthermore, facility-level constraints persist. Dr Sambo points out that some PHCs suffer from severe staff shortages, operating with a single midwife when the National Primary Health Care Development Agency guidelines require four. Drug stockouts and infrastructural challenges, such as stolen electricity and water installations, also create barriers to consistent care.
In the past, similar government-led transport programmes in the state hit a sustainability wall. When vehicles broke down, maintenance funds dried up. Drivers then began demanding out-of-pocket fuel support from low-income families, making the system unreliable and unfair.
