Democratising Global Healthcare
British Vogue, 2020
Nigerian leader and renowned advocate, Her Excellency Toyin Saraki, on how WhatsApp could revolutionise women’s healthcare across the globe.
In a remote village outside the Nigerian capital of Abuja, a woman sells clean water that she’s boiled, filtered, and put into little plastic pouches to thirsty passers-by. Her name is Olivia, and she’s 29 weeks pregnant with triplets on the way. Olivia is well aware that this is a high-risk pregnancy, so as soon as all signs point to premature labour, she acts fast. She whips out her phone and swipes her way straight to WhatsApp as though her life depends on it — because it does.
Nigeria can be a scary place if you’re about to give birth. According to the latest Child Mortality report from the United Nations, Nigeria has one of the highest neonatal mortality rates and, when combined with India, these two countries alone account for a third of the world’s under-five deaths. Outcomes for Nigerian mothers are just as troubling considering they have a 1 in 22 lifetime risk of dying during pregnancy, childbirth, or postpartum compared to that of 1 in 4,900 in most developed nations. While these harrowing figures expose inequities within healthcare services and the chasm between Nigeria’s rich and poor as the more obvious determinants of maternal mortality, a lack of adequate antenatal education is also a key factor. When a woman is armed with knowledge about her body, she can become the leader of her own health and a decision-maker in the health of her family. But if access to this information is limited, or worse, nonexistent, her path to motherhood can quickly turn into a fatal journey.
But not for Olivia — not even when she’s refused admission to hospital until a deposit beyond her financial capacity is paid. Because not only did that WhatsApp message reach the qualified midwife who’d been coaching Olivia throughout the entirety of her pregnancy, it rode the cyber waves straight to the screen of Her Excellency Toyin Saraki, former First Lady of Nigeria’s Kwara State. Saraki is the founder and president of The Wellbeing Foundation Africa (WBFA), a Goodwill Ambassador to the UN, and a renowned advocate for maternal, newborn, and child health and ending gender-based discrimination and violence. When she learns that a woman has encountered a roadblock in what is already sure to be a cumbersome delivery, Saraki, en route to the airport at the time, shows up to the hospital to cover the cost of the emergency cesarean section and ensure all three babies and their mother make it out alive.
“By the time I landed in London, [Olivia] had had the most gorgeous triplets. And she had them safely,” Saraki says. “But when I was listening to her that day at the hospital, [it was clear] what a thin layer there is between resources and the woman, and then between life and death of the child.”
It’s not unusual to find Saraki pacing the hallways of maternity wards across the country, observing, inquiring, and insisting upon the protection and preservation of the lives of women within them. While the honour of naming the country’s first-born child each year is what typically draws a First Lady into Nigerian hospitals, Saraki’s interest in this space transcends official duty. She is a familiar face in the medical world, working the healthcare circuit the same way a dignitary like herself might float from one regal soiree to the next. If you liken Saraki to a guardian of maternal wellbeing, then consider the care providers she employs an army of angels, swooping in where Saraki sees the healthcare system is falling short. Her MamaCare programme, a midwifery initiative within the WBFA, is one of the best examples of this. The programme’s free antenatal classes are available in 570 hospitals, both public and private, in six of Nigeria’s 36 states. They are led by trained midwives who give practical information, advice, and support to mothers before and after childbirth, servicing over 200,000 women since 2015 – each with her own story of survival, against all odds.
It was Saraki’s personal birthing experience that brought about such steadfast advocacy. On the eve of her wedding in 1991, Saraki, then just 28 weeks pregnant with twins, went into labour. “I went to the bathroom and realised the babies were on the way… I screamed and then they sort of carried me spreadeagle to the labour room,” she recalls. The pandemonium that ensued had Saraki fighting for her own survival and for that of the two tiny humans growing inside of her, one of which she ultimately lost due to complications during an emergency C-section. It was a tragedy that not even Saraki’s tremendous privilege as a woman of means in a vastly poverty-stricken country could prevent, and one that’s all too familiar to hundreds of thousands of Nigerian women each year. And while this loss undoubtedly gouged a hole in Saraki’s heart that can never be filled, within that hole grew a renewed sense of purpose.
“There I was, I had this 28-weeker, 1.2 kilos, in an incubator in a country where power goes every hour,” Saraki remembers. “And there began the struggle… It really showed me what was missing in my country, because that was actually the best hospital, and probably the most competent doctor, but still there were these gaps, and these gaps cost a life and almost cost me my life, too.”
And so the WBFA was officially launched in 2004, and subsequently, its MamaCare initiative — a glimmer of hope that shines through Nigeria’s grim maternal and infant mortality rates which, despite being on the decline since Saraki lost her baby in the early ’90s, consistently rank among the worst on the planet. But with a 100% survival rate for its mothers and their infants, MamaCare is an anomaly. It’s an evidence-based example of health equity in action and a case study on the benefits of care dissemination through holistic, sustainable initiatives that fully engage the recipient through free and direct communication with their caregivers.
This community-oriented approach is inspired by Saraki’s learnings from past work with Dr. Maurice Albertson, co-founder of the non-profit organisation Village Earth.
“Maury once said to me: ‘If you really want to know how to help people, you have to ask them questions. You don’t just come with your help like Lady Bountiful and expect it to work.’ Every community knows its own challenges and they know the solutions that they want, but they might not know how to get them.”
The progress already made at a subnational level in areas like Kwara State, where all WBFA programmes including MamaCare are underway, is proof of these benefits. Kwara is one of the poorest states in Nigeria —“flyover country,” as Saraki puts it — but it has already achieved the UN’s 2030 sustainable development goals target for neonatal and under-5 mortality rates. In addition to the local government’s emphasis on subsidised healthcare, the statewide implementation of initiatives like MamaCare allows for those who are both socially vulnerable and from ethnic classifications typically deemed high-risk to feel equipped for the childbearing process. MamaCare’s WhatsApp groups, which are organised and monitored by a bevy of indefatigable midwives, are a thriving digital arm of its mission (Saraki describes them as some of the most “amazing things on this earth”) and yet another avenue through which knowledge and support can be effectively funnelled to expectant mothers.
We all know what it’s like to be tethered, begrudgingly, to an endless virtual exchange of trivialities between oft-unidentifiable avatars in which we feel obligated to remain – sometimes at the cost of our own sanity. The mere utterance of the words “WhatsApp group” can incite an eye-roll or sense of dread as a result. But MamaCare’s WhatsApp world is far from your typical online talkfest. It’s a safe space for pregnant women and new mums in Nigeria to connect, commiserate, and voice their honest concerns — including the stuff deemed uncomfortable or taboo — knowing they can count on getting a prompt, accurate response in return. The midwives, sometimes referred to endearingly as “Mama” by their group members, field questions about everything from breast feeding and nutrition to pregnancy sex and postpartum spotting. “Can I take bitter kola?” asks one participant as another chimes in, enthusiastic and intrigued. In a separate group, a woman wants to know why air is coming out of her vagina, and she doesn’t hesitate to go into further detail upon the midwife’s request even with the eyeballs of over a hundred women following along from their respective screens.
“For a country with such a dire mortality rate, it’s quite clear that these questions need answering,” Saraki says, adding that this is particularly true in an environment where the rapid spread of misinformation can have cataclysmic consequences. Nigeria’s polio immunisation campaign, for example, faced a number of worrying setbacks at first due to rumors that the vaccine caused infertility, then later because of false claims that it was part of a ploy to infect children with the Monkey Pox Virus. MamaCare’s midwives can intervene immediately to dispel the maternity-related myths or falsehoods that manage to seep into these shared platforms before any further damage is done.
While WhatsApp was initially intended to function in tandem with MamaCare’s educational programming, these online conversations have started to shape the in-person classes so that the material covered is tailored to the specific needs and interests of each group. Plus, a class is limited in the number of attendees it can accommodate — Saraki says that’s anywhere from 12 to 90 women depending on the size of the hospital — but a single WhatsApp group can have up to 256 women in it at once, which means MamaCare’s online reach far exceeds its physical presence. Although the ability to have and use technology presents a significant barrier in terms of access, the number of internet subscribers in Nigeria has now exceeded 147 million (much more than half of its population), the majority of whom are getting it on their phones. With both mobile penetration and smartphone adoption expected to increase significantly by 2025, MamaCare is poised to grow correspondingly.
The groups have proved so successful throughout the COVID-19 pandemic that the WBFA is formally committing to an official MamaCare WhatsApp ‘chatbot’, set to go live this October. “When COVID started, oh my God! Our WhatsApp groups went completely crazy,” Saraki says. The pandemic certainly weakened the resilience of healthcare systems around the globe, but childbirth, she reminds us, doesn’t stop for anyone, anywhere. The urgent need for guidance, answers, and a network of support for already-anxious mums-to-be was exacerbated as soon as the virus struck. By turning to WhatsApp to help women navigate this unfamiliar territory, MamaCare midwives had the opportunity to quell the fears of their patients, a service that has persisted long after their in-person antenatal classes were permitted to resume.
By zealously harnessing the power of digital communication through vehicles like WhatsApp, Saraki believes MamaCare will amplify its impact. What’s currently reaching 8,000 mothers a month, she says, can soon evolve into well over 200,000. And with about seven million babies born in Nigeria each year and Saraki’s goal of providing every single one of them and their families with a safe delivery and quality care, the WBFA chatbots are a major step in fast-tracking that ambition.
“Our tech is going to underpin our frontline. We want to be able to deliver lessons, immunisation reminders, nutrition advice, all by WhatsApp,” Saraki explains excitedly. “Imagine the sort of scale we can have when we launch the chatbots — it’s going to be revolutionary!”
The old adage that knowledge is power may be wildly cliched, but the positive results coming out of Kwara state affirm its truth. If something as obtainable as WhatsApp has the capacity to improve medical outcomes for Nigeria’s most disadvantaged women through the diffusion of reliable information, then the world might not be as far from widespread healthcare reform as we thought.
Consider the United Kingdom, where maternal mortality rates are low but the gap between outcomes for Black and brown women compared to those of their white counterparts is wide (and widening). There is no lack of abundant antenatal classes and WhatsApp groups for expectant mothers in the UK, but what’s missing is the availability of care that’s designed for the needs of the country’s marginalised communities. A one-size-fits-all method doesn’t work for a population that’s as ethnically, racially, and financially diverse as the UK’s, especially when minorities rarely see themselves reflected in the medical personnel delivering this care (in a June 2020 statement on race from the Royal College of Midwives, the organisation referred to itself as “overwhelmingly white,” and a recent report from the Nursing & Midwifery Council shows that about 85% of midwives in the UK identify as white). If a Black woman is five times more likely to die during childbirth in the UK, a more culturally sensitive approach to understanding these discrepancies and educating healthcare professionals and their patients accordingly can and will save lives.
When asked if delivery by way of WhatsApp is on the horizon, Saraki laughs – but she doesn’t rule out the possibility. What she is sure of, however, is that the role of data collation and analysis is crucial to the evolution of egalitarian healthcare systems. “When we’re at a crossroads and we’re not sure what to do, data, if it’s openly and freely available, can lead us forward,” she says. “You can’t access data if you’re not accessing tech, and I’m hoping that the WBFA’s use of technology will add this extra layer to all of our programming, and democratise it.”