Dr. Aduragbemi Banke-Thomas is an Associate Professor of Maternal and Newborn Health at the London School of Hygiene and Tropical Medicine, United Kingdom. He is also a Visiting Professor on the Erasmus Mundus Europubhealth Programme at the University of Greenwich. A public health practitioner, and global maternal and newborn health researcher, he is currently the Principal Investigator for the Google-funded project, On Tackling In-transit delays for Mothers in Emergency (OnTIME). In this interview with IJEOMA THOMAS-ODIA, he shares his drive for ensuring that pregnant women in emergency situations get timely access to care.
What informed your passion for medicine with focus on child and maternal health?
That’s very interesting. Right from Medical School, I had always identified maternal health as a field I was particularly passionate about. I loved obstetrics. I felt like if you looked at medicine as a whole, obstetrics is one area where you can become an instant hero. The mother is crying and in pain, and you do your magic, the baby comes out, and you become a hero instantly. However, despite me enjoying obstetrics and always feeling like I have done what I needed to do here when it comes to one woman, I quickly started getting frustrated by the fact that it was one woman I could help at a time. And yet there are so many issues that influenced or affected how this woman accessed care, her experience of care, or the outcome of the care that had nothing to do with the care that she actually received. So many of those issues happen before she actually got to the hospital.
And so quickly I realised that I needed to redirect my career towards a place where I would be able to make an influence on those things that affected her. And that looked more like public health and policy side of things, so I started building my career towards that. I am extremely passionate about improving outcomes, care and accessibility for pregnant women in Sub Saharan Africa. Till today, it baffles me that a woman can get pregnant and take it for granted that she is going to deliver her baby safely. The great women in this part of the world we greet them Eku Ewu Omo – which is almost like giving them greetings on the travails of pregnancy, and I feel it shouldn’t be that way. Every woman should be able to decide on her own when she wants to get pregnant and look forward to a safe delivery for herself and the baby, and that is what I am really passionate about – to ensure that I am able to contribute to efforts to reduce maternal and prenatal mortality.
With your passion for ending maternal mortality in sub-Sahara Africa, how were you able to come up with the OnTIME concept and how do you go about it?
There are many things that contribute to maternal mortality. This is just one part of it. I have contributed across the different spheres, including training health care providers to be able to provide emergency obstetric care – different ways in which I have contributed. This particular space on maternal care has been a project that I have been chasing since 2015. In 2015, I used to work with the late Senator John McCain in the United States under his organisation, the McCain Institute. Then, it was always about my concern about this middle gap. We talked about the three delays that contribute to maternal mortality. With the first delay, which is the delay in deciding to seek care, we have an opportunity to interface with the woman when she comes to antenatal clinic.
We can tell her to come to hospital when she notices certain signs. With the third delay, which is the delay in provision of care, that is when we get to the health facility. For the health worker, it is about providing the care right there, when it is needed. During travelling to get care, when there can be a delay, the woman is on her own. We just expect her to arrive at the hospital. I have always called this space a ‘black spot’. We don’t know what goes on. That was one of the things that drew me into this space; how can we better understand what is going on here, because we know that many women are dying because of delay in travel to reach a health facility that can provide the care that they need. This effort has really been about trying to unravel this black box; to really understand what goes on here. I have been able to inform the government and other stakeholders who can make a difference on what needs to be done in addressing these gaps, and hopefully contributing to reducing maternal mortality that can arise as a result of delays in this second phase.
Do you see this as a global issue?
It is a global issue, but Nigeria is a big part of it. Not less than 282,000 maternal deaths occur every year – that is the latest estimate from the World Health Organisation – and Nigeria alone has 87,000 of these deaths happening in one year. That’s a huge number; about a third of the total global deaths occur in Nigeria alone, so it is a huge problem. We have been so grateful for the support we’ve gotten from Google. Google supported phase one of this project, which was done in 15 cities that have populations of over a million in Nigeria. And we just got started with phase two of the project, which is now going across Africa. We are targeting 13 cities across Africa – main capital cities in 13 countries. We know there is a need to focus on urban areas because there is this wrong perception that women in urban areas are ‘fine’, but that’s not true. And the rural women are the ones that have difficulty in accessibility, but with slums expanding and a lot of informal settlements growing, the reality is that women in urban areas are losing this so called ‘urban advantage’. There is difficulty in access here, there are poor outcomes also happening in the city. So, we need to really understand what is going on in urban cities. This project has begun in Nigeria. We’re doing it now across Sub Saharan Africa, and we will be moving to South East Asia and Latin America; one step at a time.
Did the Japa syndrome affect your case too?
No, it wasn’t. I had left before the Japa phase. I didn’t leave to Japa. I just left to pursue opportunities. I got an European Union scholarship to study abroad. I went for that and got my PhD. I have always kept the link between Nigeria and myself. My work is only meaningful in countries like Nigeria. So, I am in Africa every two or three months. To be honest, I just see myself as living across two continents.
How has the Japa syndrome contributed to the high maternal mortality?
Those that think that we have enough doctors are deceiving themselves. We do not have enough doctors. We are bleeding doctors every day. Not sure how many of my classmates still remain in the country, to be honest. The problem I see now is that many health workers are leaving Nigeria without a clear appreciation of what role they can play in the health system. It is almost a case of going and not looking back. It looks more like the escape of the Israelites from Egypt, rather than an opportunity to improve on their skills and then come back and give back to society. That’s what I am struggling with right now. There are two types of Japa. There is a Japa with a purpose, and there is a Japa without a purpose. But if you want to put it in a different way, there is a Japa ‘I am running’ or there is a Japa ‘I will see you soon’. Those two things need to be put into context.
How do we put those things into the context of maternal mortality?
You may have an hospital built – public or private – if you don’t have the human capacity to provide care there, you might as well just destroy the hospital as a non-existent facility. We do need help to make these services available, we need doctors. More importantly, we need a pipeline of doctors and if there is anything that worries me the most, it is this decreasing pipeline, where medical students in Nigeria are already planning to write foreign exams even before they graduate. No one is thinking of practising in Nigeria. I don’t think there’s any medical student who’s thinking of doing the residency programme in Nigeria and becoming a consultant. Everybody is thinking about leaving the country. I think it is a huge problem that the government needs to take quite seriously. We need to improve remuneration of health workers, especially doctors, improve their working conditions and also offer incentives to those who have left to be able to return. It is not just about preventing people from going, but also seeing how you can attract those who have left to come back. There are countries like Singapore who have been able to do this quite well. They let their brains go, but also then offering incentives for them to come back. I do not see the Japa phenomenon as final; I see it as a process. There’s still huge opportunities for the government to innovatively engage these doctors who have left, to see how they can be made to return at some point in their career.
Your project is focused on access to choice healthcare facilities for women who are bearing children. How available are these facilities?
The truth is that we do not know what women want right now. We only incorporate their element of choice in this dashboard, which are the first, second and third nearest public and private facilities. What we are hoping to do in the future is to add several layers on top of this. We want to add layers on the cost it takes for them to access care in those facilities. We want to add a layer on the perception of the quality of the care. Can women give a five or four star rating to health facilities, which we will now add on top of the dashboard to the rating for that health facility? This would ultimately stimulate health facilities to want to do better and provide better care for women who patronise their services. We also want to incorporate things like bedspace availability. The number of health workers who are available to provide certain services. We want to incorporate all these things into this dashboard, but this is the first step and we look forward to implementing it in the future.
In your years of experience and practice, what lessons has your profession taught you?
That’s a very big question. I wasn’t ready for that. I think it’s really the fact that there is a myriad of problems out there that we as public health experts and people who work in this space generally cannot look away from, whether we like it or not. It is not enough for a certain percentage of the population to enjoy certain benefits, while others are left out. Some people describe it as inequity – of nothing out of their own doing. But somehow, the society is organised in such a way that this group of people are benefitting and these group of people are not. It is not right. Every time we see that bit of injustice, we have the intellect, the wisdom, and the knowledge to be able to make a difference to ensure that we address these inequities and inequalities that exist in our society. We cannot see it and look away. That, for me, is a big takeaway from my profession. Let’s not look away from the inequities; let’s figure out a way that we can communicate, ways to fix them. That is where the change happens.