Midwives’ silent struggle: Delayed p PPlunge Niger State healthcare providers into financial distress, debts

OVERDUE salary payments are plaguing midwives enrolled in the Midwives Service Scheme (MSS) within Niger state’s Bida, Paikoro, and Lapai local government areas (LGAs). These salary delays, stretching over six months in one year, have placed significant financial strain on the affected midwives and their families. 

At the core of the crisis

In the heart of Niger state’s Bida, Lapai, and Paikoro LGAs, the distressing reality faced by midwives grappling with delayed salaries, promised under the Midwives Service Scheme (MSS), is blunt, shedding light on a broader issue of systemic shortcomings.

A mother of six, Safiya Kabiru Usman, embodies the struggles of these essential healthcare providers, grappling with the financial uncertainty that impedes their ability to fulfill their vital duties.

Usman finds herself in a financial bind, unable to meet basic needs for her family due to the absence of her expected income.

Her situation mirrors that of others such as Salima Mohammed and Aishat Ummi, whose reliance on monthly wages has been destabilised by recent payment delays.

 Financial strain amid personal sacrifice

In narrating her ordeal, Usman reflects the ripple effects of delayed payments. She said since February, she has been awaiting her salary, a delay that has not only strained her finances but has also impacted her family’s well-being.

Sadly, her experience is not an isolated one because fellow midwives like Salima Mohammed, Aishat Ummi Kabir, and Aishat Usman also rely on their monthly salaries to sustain their families.

Salima Mohammed’s plight, as she recounted, is particularly telling, despite a monthly salary of N62,000, a recent delay has left her stranded during a crucial moment, forcing her to take out a loan to cover expenses.

Typically, she sets aside a portion of her income for monthly contributions, but because of the delay, she had to forgo this savings to be able to fall back on in the nearest future.

Midwives missing in action, intern nurse overwhelmed 

The scene at the Engr. A. A Kure Primary Health Care Centre in Efun Makodi Area, Bida LGA, paints a true picture of the healthcare crisis unfolding.

With over 100 nursing mothers and children awaiting immunisation, the facility had only an intern nurse and a volunteer present, highlighting the absence of government-employed midwives.

The officer-in-charge, (OIC), Fatima Yusuf, voices her dismay as three designated midwives have been missing for months, citing systemic flaws in the selection process and the deployment of assigned midwives from the local community.

Yusuf observed that similar concerns persist in other healthcare centres across the LGAs, where irregular attendance by midwives disrupts essential services. She added that this shortage of midwives has serious consequences for maternal health, contributing to alarming mortality rates in rural communities.

Despite efforts to enhance healthcare, Nigeria still struggles with preventable deaths due to insufficient maternal and neonatal care, she disclosed.

To address mounting challenges, the Niger state government, she said, purportedly allocates substantial funds to strengthen primary healthcare.

Nevertheless, the persistent delays in salary payments continue to impair ongoing funding issues, affecting the livelihoods of frontline workers.

Challenges prompting resignation 

Amidst the hardship caused by irregular payments, Aishat Ummi Kabir considers resignation, citing unbearable financial strain as she shares her story. Her thoughts find resonance with nurse Idris Moi of the National Association of Nigeria Nurses and Midwives (NANNM), who emphasised the unjust burden on healthcare personnel.

Government officials also acknowledge the problem to the reporter, attributing delays to funding gaps and communication lapses. However, despite assurances of action, concerns persist regarding the efficacy of current measures in addressing systemic issues.

Midwife shortage amid rising maternal mortality

Insufficient midwives in rural primary healthcare settings have heightened maternal mortality rates, as they play a crucial role in prenatal, delivery, and postnatal care, detecting and preventing complications.

In fact, the lack or shortage of midwives in Niger’s Primary Healthcare system has resulted in unsafe births and untreated post-partum issues, worsening preventable maternal mortality.

According to reports from the World Health Organization (WHO) and the World Bank, despite some improvements in recent years, Nigeria still grapples with a high maternal mortality rate, currently standing at 821 per 100,000. Specifically, in Niger state, this rate is 130 per 100,000, with under-5 maternal mortality at 103 per 100,000 live births and an infant mortality rate of 260 per 100,000 live births.

Shockingly, in Niger state, one out of every 95 women succumbs to pregnancy-related complications, resulting in an estimated annual toll of 1,934 deaths.

Most of these tragedies occur in rural and hard-to-reach communities, primarily due to the challenging terrain of the state, as the reporter found out.

Across all local government areas in the state, the leading causes of maternal mortality include post-partum hemorrhage (PPH) and eclampsia – a severe complication of pregnancy characterised by seizures, often occurring after high blood pressure (pre-eclampsia) has already been diagnosed, according to health officials.

Similarly, they noted that birth asphyxia and neonatal sepsis – these are conditions where a newborn baby is deprived of oxygen, either during pregnancy, labour, or delivery, leading to potential complications such as brain damage or even death.

And as for the neonatal sepsis, it is a bacterial infection that occurs in the bloodstream of newborn babies, typically within the first month of life and often lead to serious complications if not promptly treated, including organ failure and death. And either of these can emerge as significant contributors to neonatal mortality in the state.

Accommodation challenges compound Midwives’ struggles

In 2023, when Nakiyyah Usman, a Midwives Service Scheme (MSS) recipient, received her appointment letter, her elation knew no bounds. She had fervently hoped to be assigned to a nearby facility, envisioning a relief from the strain of accommodation and transportation costs that burdened her.

Despite her salary mirroring that of her peers at N62,000, Nakiyyah found herself shelling out at least N2,500 each day on transportation and meals alone.

Her weekly routine of approximately 43 minutes (22.4km) unfolded with her working three days at Tutungo PHC in Paikoro LGA while residing in Maitumbi, the heart of Minna, the state capital.

Lamenting a similar fate was also Aishat Usman, another beneficiary of the scheme who shared her daily odyssey from Minna to Lapai, painting a picture of the daily struggles faced by many in the project. Minna to Lapai is a one hour 34 minutes (69.9 km) journey.

“Every day, the long commute wears me out,” she said, highlighting the physical exhaustion she suffers. She also faces significant financial strain, noting that “the cost of transportation takes a large part of my earnings.”

The emotional toll is also heavy, as she explained that “being away from my family for so long is very difficult.”

The same goes for Zainab Hussaini Goni, also a beneficiary, who illuminated on the hurdles she encountered, ranging from delayed salaries to the perpetual issue of inadequate housing.

For Zainab, being a mother further compounded her challenges as she shuttled between Minna and Lapai every week day due to the absence of government-provided lodging.

Karima Umar, a midwife nestled in the Fadipke neighbourhood of Minna, echoed similar sentiments, stressing that a big chunk of her income is devoured by transportation and sustenance costs.

She fervently appealed to the government to devise concrete solutions to alleviate these hardships, emphasising how such measures could empower midwives like herself to render even more effective services to their communities.

Funding shortfalls and operational disruptions

In its 2024 budget, the Niger state government notably placed a significant emphasis on bolstering the health sub-sector, earmarking a substantial sum of N42.7 billion.

A notable initiative found within this allocation is the establishment of the state Ministry of Primary Health Care intended to signal a strategic move towards enhancing the accessibility and quality of healthcare services at the grassroots level.

Additionally, a considerable portion of the budget, amounting to N2.253 billion was set aside for the transformation of the Shiroro Hotel into a teaching hospital.

This transformation, it was believed, holds promise for expanding healthcare infrastructure and improving medical education within the state.

And to complement this endeavour, a further N968.751 million was allocated for the procurement of essential medical equipment, ensuring that the newly established teaching hospital is adequately equipped to meet the healthcare needs of the populace.

Despite a substantial injection of N56 billion from the Basic Healthcare Provision Fund (BHCPF) for initiatives such as midwife training, challenges persist in the healthcare funding landscape.

These funds were expected to impact timely disbursement of worker salaries, yet significant obstacles continue to hinder effective healthcare delivery.

In response to the pressing need for skilled healthcare professionals, the state’s Primary Healthcare Development Agency (SPHDA) explained that it has embarked on a recruitment drive, hiring approximately 200 midwives.

These midwives, it was noted, have been strategically deployed to BHCPF-funded facilities across the state’s 25 local governments, aiming to strengthen the frontline healthcare workforce and improve access to essential services in underserved communities.

Staff absenteeism plagues Lapai LGA PHCs

During a visit by the reporter to the Takuti Shaba Primary Health Care Center (PHCC) in Lapai LGA, it was found that the facility opened but bereft of any staff, despite an hour-long wait. The OIC of the centre, Gambo Takuti, acknowledged that three midwives from the MSS were assigned to the facility, yet none were on duty.

He attributed this absence to a likely official assignment elsewhere. He could not explain what this assignment could be.

Similar absenteeism was observed at the Comprehensive Primary Health Care Lapai and the Modern Primary Health Care Paiko, where an undisclosed number of MSS beneficiaries failed to report for duty.

The OIC of Comprehensive PHC, Abdulkadir Danteni Mohammed, conceded to the absence of the midwives, attributing it to a lack of commitment among staff members.

The Head of the Maternity Unit at the same facility, Ramatu Garba, identified midwives Habiba Mohammed, Zainab Mohammed, and Murjanatu Mohammed as frequently absent, citing sporadic attendance as the issue.

At the Modern PHC Paiko, the OIC, Bawa Sabo, acknowledged the midwives’ absence but defended their commitment, stating that they have been providing assistance despite logistical challenges and delays in salary payments.

Nurse shortage hurts mothers 

Accessing adequate antenatal care remains a daunting challenge for many expectant mothers like Aisha Musa.

Her journey to the Comprehensive Primary HealthCare Centre in Lapai is always filled with frustration and disappointment as she narrated to the reporter.

“When I visited the centre, there were not enough nurses and no drugs available,” she related. “The few nurses present often seem distracted, leaving us waiting for hours.”

Musa is not alone. Many women in Lapai, including Habiba Ibrahim, share stories of neglect and substandard care.

Ibrahim vividly recalls her traumatic ordeal during labour.

“A nurse refused to examine me properly and sent me home, saying my pregnancy wasn’t due for delivery. I had to deliver my baby in my living room, with only my neighbours to help,” she said fighting back tears welling up in her eyes.

“This is the reality of Niger’s primary healthcare system, where understaffed and under-equipped facilities struggle to meet the needs of expectant mothers. Whereas, there should be more qualified nurses and better facilities,” asserts Hajara Umar, another resident of Bida.

“We often wait for hours just to be seen and attended to,” she further quipped.

“And the consequences of these deficiencies are profound. One of such is that, many women, disillusioned by their experiences, opt for traditional midwives or even home births despite the risks. So, improving these services is crucial,” repeated Musa, adding that “every mother and child deserve better health care treatments.”

Ineffectiveness of PHCs in LGAs 

A director within the local government’s Primary Health Care (PHC) system, who pleaded for anonymity with lest they would be victimised, expressed apprehension regarding the efficacy of the MSS in the region.

She disclosed that among the 14 midwives designated to the PHC in her LGA, only three consistently discharge their duties, with the others exhibiting irregular attendance because some of them no longer reside within the LGA but commuting from Minna and Abuja, thereby limiting their ability to effectively serve the local populace.

The health worker added that some of the midwives are former students who have since graduated and moved away for the area.

She also noted that despite lodging numerous complaints with state authorities, no corrective measures have been initiated.

She said a reevaluation of the recruitment process to prioritise dedicated individuals willing to work and reside locally had been proposed but further actions is still being awaited.

Subsequently, she advocated for giving preference to residents of host communities during recruitment and involving LGA authorities to ensure accountability.

Additionally, she suggested the utilisation of Community Health Extension Workers (CHEWS) who are already trained and available while stressing the importance of state officials engaging with the community to identify suitable candidates willing to serve effectively in rural areas.

Global midwife shortage looms large by 2030  

With Africa and Nigeria facing pressing challenges despite their indispensable role, midwives are in short supply worldwide, with a projected need for 900,000 additional midwives to meet current demand.

By 2030, an estimated 1.3 million more midwives will be necessary, but only 300,000 are anticipated to be available.

Africa, in particular, grapples with a significant shortfall, with midwives addressing just 43 per cent of maternal and reproductive health needs.

In Nigeria, the scarcity of midwives is compounded by a dearth of data on their current availability. For instance, a World Bank dataset spanning 2013 to 2019 reveals no recorded figures for the number of midwives per 1,000 people, creating a crucial information gap.

Worker considers quitting over financial strain  

A resident of Minna, Aishat Ummi Kabir, expressed her worries regarding the persistent delays in receiving her salary and hinted at the possibility of resigning from her job due to the financial strain caused by the situation.

She lamented the challenge of daily transportation expenses, which has almost turned her into a beggar as she has to borrow money to meet her needs for without any guarantee that she would be able to pay back.

She also criticised the disparity in government salary levels, stating that she is unable to sustain herself under such conditions.

Kabir cited her recent absence from work because of not being paid her salary on time, adding “Living in Minna and commuting daily from Paiko has been imposing a dire financial strain on me.”

Niger nurses decry dire conditions under MSS scheme

“The current condition of the MSS scheme is deeply troubling,” stated Moi, who is the Public Relations Officer of the National Association of Nigeria Nurses and Midwives (NANNM) in Niger state.

“Our nurses and midwives are grappling with delayed and insufficient salary payments,” he emphasized, shedding light on the challenges faced by healthcare personnel.

“In a profession pivotal to public health, remuneration and compensation should be commensurate with the importance of the role,” Idris asserted.

“But expecting nurses to maintain dedication amidst meagre wages is unrealistic and unsustainable.”

He further noted, “Additionally, it’s impractical for the government to anticipate staff, often deployed away from home, to cover essential expenses with inadequate reimbursement.

“So, improved remuneration, effective communication channels, and accountability mechanisms are essential to address the systemic challenges plaguing Nigeria’s healthcare system.

“Also, in light of these pressing issues, concerted efforts at the governmental, institutional, and community levels are imperative to ensure equitable access to quality healthcare services and safeguard the well-being of both healthcare providers and the communities they serve,” he remarked.

NPHCDA staffing guidelines for Nigerian healthcare

The National Health Care Development Agency (NPHCDA) sets standards for staffing at primary healthcare centres in Nigeria to ensure effective care delivery. According to these standards, each centre should have one doctor for every 1,000 people, aligning with global health service recommendations.

Additionally, there should be at least two nurses for every doctor to enhance patient care.

For optimal functioning, primary healthcare centres should also include one midwife per 500 people, one community health worker per 1,000 people, and one laboratory technician per 5,000 people.

Adequate staffing is crucial to address healthcare disparities, minimise long wait times, and provide comprehensive and timely care for both routine and emergency situations.

Reporter documents midwives’ struggles with transport costs on bad roads

For a first-hand experience of what it takes a particular absentee midwife to commute back and forth to her LGA in Minna to Bida LGA along the Minna-Bida Road, this reporter embarked on a fact-finding mission cruise. Going on the journey reveals a stark illustration of the transportation challenges faced by specific midwives plying this route.

Once a simple one-hour drive, this outing currently extends to over three hours due to the deteriorating road conditions.

Riding in a commercial vehicle, this journalist experienced the daily hurdles that midwives endure on their way to work, compounded by the issue of delayed salaries.

He recounts how much he spent on a fact-finding round trip summing up to N6,500. This experience gave him the clue on the weighty financial burden on the healthcare workers which he had earlier been made to understand was one of the factors for their absenteeism.

Having been told that earning a monthly salary of N62,000 and traveling five times a week, the midwives said they usually end up spending N32,500 on transportation, which constitutes 52.61 per cent of their monthly earnings; that made it hard for them to be able to go to the PHCs regularly.

As the reporter returned to the PHC, from where he commenced other activities, he realised the stark illustration of the heavy financial strain placed on midwives by transportation costs, that consumes some notable portion of their modest and delayed incomes.

Coupled with the physical toll and safety risks associated with traveling on such poor roads, this reporter observed the considerable difficulties midwives face as they continue to provide crucial healthcare services in their communities despite infrastructural shortcomings and delays in wage payments.

Health director blames exhaustion of FG’s counterpart funds 

Reacting to the complaints on delayed payment of midwives’ salaries in the state, Inuwa Junaidu, the State Director of Health Planning, Research, and Statistics, acknowledged the issue, revealing that beneficiaries have not received payment since February.

He attributed the delay that the state had finished the federal government’s counterpart funds allocated for the scheme, highlighting the need for additional funding.

Junaidu also addressed absenteeism among health workers, stating that salaries would be halted for those found absent, though he noted a lack of communication between frontline agencies and state officials. But he gave assurances that all complaints would be addressed promptly, stressing the importance of effective communication channels.

Regarding equipment deficiencies in healthcare facilities, Junaidu outlined fund disbursements from the Basic Healthcare Provision Fund (BHCPF), with facilities receiving financial allocations for necessary equipment.

Yet despite efforts, challenges persist in ensuring adequate equipment provision.

Expressing concerns about scheme implementation, Junaidu emphasized the necessity of collaboration between the state government, PHC directors, and World Development Committees (WDCs) in all LGAs.

Also acknowledging logistical challenges in supervising remote areas, Junaidu emphasized ongoing efforts to improve accessibility and oversight in Niger state’s healthcare system.

Expert urges rapid action to curb high maternal & infant mortality rates 

Renowned radiation medicine professor at the University of Nigeria, Nsukka (UNN), and the University of Nigeria Teaching Hospital Enugu (UNTH), Ifeoma J. Okoye, sounds alarm on Nigeria’s persistent healthcare crisis.

She said there are serious concerns regarding the ongoing high rates of maternal and infant mortality in Nigeria and despite concerted efforts, recent research indicates that the nation’s objectives for reducing these alarming rates remain unfulfilled.

In light of these sobering findings, Okoye also called for urgent and targeted interventions to tackle this pressing issue head-on as she emphasizes the critical necessity of overhauling primary healthcare systems at the grassroots level to enhance professionalism and efficiency.

Okoye further advocates for a significant improvement in the attitude and compliance of healthcare workers towards their responsibilities, alongside robust monitoring mechanisms within primary healthcare facilities. 

She then stresses the importance of offering better remuneration packages to healthcare professionals in rural areas as a notable way to bolster productivity and combat challenges such as the “Japa syndrome.”

Moreover, Okoye emphasizes the vital need for adequate working materials and equipment across healthcare facilities, coupled with a reinforced referral system to ensure prompt access to specialised care for high-risk cases.

She also highlights the importance of equipping expectant mothers with knowledge about pregnancy danger signs, alongside enhanced data collection and analysis methods to pinpoint causes and implement effective solutions.

• This report republished from Crispng was made possible with support from the International Budget Partnership (IBP), and the International Centre for Investigative Reporting, (ICIR) under the Strengthening Public Accountability For Results and Knowledge (SPARK 2) project.