On a Monday in July, as it does several times a week, the Unit 4 health centre in the community of Parcelles Assainies, located in the suburbs of Dakar, Senegal, is offering free vaccination sessions for infants under the age of two. Surrounded by crying babies and in between two injections, Ndoungou Mbaye talks with the mothers sitting in the courtyard. She explains to Coumba, a 25-year-old first-time mother, the importance of vaccinating her child. She also takes the opportunity to make her aware of family planning, even though "in Senegal, often you can only use it after you have had several children."
Ms. Mbaye is a Bajenu Gox, a "neighbourhood godmother" in Wolof. Neither a nurse nor a midwife, the Bajenu Gox is most often an experienced woman respected in her community. She passes on her knowledge to all women, whether they are teenagers, newlyweds or mothers, an act of intergenerational solidarity that is well established in Senegalese traditions. Custom meets science here: Ms. Mbaye is one of 85 neighbourhood elders recruited and trained as part of a five-year intervention research project initiated in 2015 by the Innovating for Maternal and Child Health in Africa initiative of Canada's International Development Research Centre (IDRC). Senegalese and Canadian researchers are supervising the project.
The goal? To breathe new life into a similar initiative launched by former President Abdoulaye Wade in 2010 in Senegal's 14 regions. It relied on 8,600 women volunteers who acted as intermediaries between the health structures and the population. "This initiative used the figure of the bajen, the ’godmother’, the father's sister who holds the role of a confidante, to entrust dynamic women, recognized leaders in their neighbourhoods, with a role in raising awareness about maternal health," says sociologist Rosalie Diop, the project's main researcher. Although they were successful in the community and in reducing infant mortality, these godmothers became distracted from their mission over time. They were exhausted by the constant demand for their services and the lack of remuneration, which prevented them from undertaking paying activities.
A Bajenu Gox since 2012 in the community of Parcelles Assainies, Mbene Diaw remembers the beginnings: "You get involved to support women and help the population, but it's complicated to carry out this activity while being a mother and holding a job. We devote all our time to it, without any financial compensation. Sometimes we would pay out of pocket for the care of women who are too poor."
It is in this context of disaffection that the research project began. The aim was to revitalize and sustain the government initiative in four locations (Dakar suburbs, Kaolack, Fatick and Louga) selected by Rosalie Diop and her colleagues, supported by the Senegalese NGO Action et Développement (ACDEV), which is in charge of implementation. The watchword: valuing women's leadership on several levels.
The weaknesses of the original initiative were addressed to keep the women motivated. In order to reach the goal of one godmother for every 10,000 inhabitants, new Bajenu Gox were selected according to criteria such as commitment and discretion. While most of the interveners are 50 years of age and older, an effort has been made to recruit younger women to work with teenagers. ACDEV then took charge of training them in health, but also in communication and management to strengthen their skills "and increase their power to act," adds Dr. Cheikh Athié, ACDEV's president. Four associations have been formally established, one for each project location. Already recognized in their neighbourhood, they are now recognized by the authorities. Finally, the project also addressed the issue of compensation for the women. We will come back to this later.
The issue of maternal and child health is one of the priorities of the Emerging Senegal Plan, set up by President Macky Sall to accelerate the country's development. Compared to other West African countries, Senegal has a rather good record in terms of infant, neonatal and maternal mortality —between 1997 and 2017, infant mortality fell from 68 to 42 deaths per 1,000 live births, according to the National Health and Social Development Plan. However, there is a need to continue to improve the country's indicators to achieve the Sustainable Development Goals of fewer than 25 deaths per 1,000 live births in all countries by 2030. In comparison, the infant mortality rate in Canada is about 4.3 per 1,000 births.
Public health messages still come up against misconceptions and beliefs, which can have dramatic consequences for the health of mothers and children. "We are in a pro-birth society where persisting common beliefs include rumours that vaccination makes you sterile. Those in power — husbands, mothers-in-law and sometimes religious leaders — still oppose certain practices, such as giving birth in a hospital or adopting family planning because of a lack of knowledge," says Diop.
In Senegal, pregnancy is hidden during the first months for fear of the evil eye. It is therefore very common for pregnancy follow-up to be late or even non-existent. "Without follow-up, there are more problems during delivery and the risk of neonatal and maternal mortality increases," says Dr Athié. Economic insecurity, but also geographical isolation, especially in rural areas, explain the low rates of visits at health facilities. "An ultrasound costs 10,000 to 15,000 CFA francs [CAD23 to CAD32]. It is common for women who are too poor not to do any," confirms Maguette Gueye, president of the Bajenu Gox of Parcelles Assainies.
After the vaccination session at the Unit 4 health centre, Ndoungou Mbaye heads to the sandy neighbourhood alleys to make home visits, one of the godmothers' key activities, in addition to giving talks (community information sessions). In the course of an exchange, she discovered that her interlocutor's four-year-old son had not had his booster shot, normally given before the age of two. The reasons are lack of knowledge and lack of financial resources. Thanks to Ndoungou Mbaye's intervention, the child will finally be vaccinated the same day, free of charge.
Reassured, the 34-year-old mother takes the opportunity to open up about her relationship problems and her personal situation. A Bajenu Gox also wears a family mediator's hat. "Tired of pregnancies, a woman was using contraception in secret from her husband, and I was hiding her health booklet. I then mediated and finally the husband congratulated me because his wife was healthier!" recounted Rouby Ba, president of the Bajenu Gox of Diaoulé. Involving husbands, as well as mothers-in-law, who are often the power holders, is essential to promoting conciliation and a change in social norms.
The success of the process depends on the commitment of the entire community, including religious leaders, who are an indispensable support in a country where 95% of the population is Muslim. Steering committees made up of religious leaders, mayors, neighbourhood leaders and community actors supervise, accompany and support these associations. "The awareness work done by the Bajenu Gox is remarkable," says Sega Sow, an imam in Diaoulé.
The research project was able to document the impact of activities undertaken by the Bajenu Gox on health centre visits and highlight their fundamental role in changing behaviours. As a result of their work, among other things, the number of maternal deaths dropped from 315 per 100,000 live births in 2015 to 236 in 2017.
This success is due in part to the close collaboration between the godmothers and the health care system. "If a patient does not come for her appointment, we call the Bajenu Gox and she pays her a visit. We also give them the names of women of childbearing age who need to be educated. In addition, they bring us new patients," says Amath Diouf, "chief" nurse who is very involved in the Diaoulé community.
Each month, the godmother is required to provide a report on the number of home visits made and information sessions given, as well as referrals. The documents are then forwarded to the health district office. But many Bajenu Gox do not complete the reports properly or at all. "They have taken the training, adapted for illiterate people, but it is still complicated for them. Many forget," sighs Fatou Kebe, a project research assistant. These inaccuracies distort the overall data collected and make it difficult to assess the work of the Bajenu Gox. But some localities have found a solution: for each report submitted, the Diaoulé association pays 1,000 CFA francs (CAD2.38). It’s a way to encourage more diligence.
Because money is still key. While social recognition and the desire to help the community were sufficient drivers for the launch of the national program, the economic reality quickly caught up with the volunteers. It is difficult to reconcile family life, economic activity (mainly in sales) and community involvement.
But how do you get the machine going again? By empowering women financially, which would also increase their self-confidence. This is the premise of the researchers, who suggested that income-generating activities be set up in parallel with this volunteer work.
Thanks to funding from Global Affairs Canada, the Canadian Institutes of Health Research, IDRC and the Fonds de recherche du Québec – Santé, four million CFA francs (approximately CAD9,500) were allocated to each of the associations in the test areas. The beginnings were difficult, but the models selected by the Bajenu Gox are now working: a food shop on credit in Parcelles Assainies, cereal processing in Kaolack or the sale of iodized salt to prevent swelling of the thyroid gland in Diaoulé. "Ideally, the activity should be health-related, such as processing cereals to combat malnutrition or selling enriched porridge for infants," adds Diop. Loans have also enabled some godmothers to start their businesses. "I was able to buy a sheep and then sell my lamb. I now have three sheep!" says Mbene Diaw proudly, from Parcelles Assainies.
Why not pay the Bajenu Gox directly? The issue has been raised, especially since President Macky Sall has asked researchers to explore various options to financially motivate the godmothers. A monthly salary, performance-based pay, a hybrid model combining the two..."The question of remuneration is central and would ensure the sustainability of the program," says Oumar Mallé Samb, a researcher specializing in global health at the Université du Québec in Abitibi-Témiscamingue. "But paying Bajenu Gox a salary would cause competition with other health volunteers such as matrons, who help with deliveries, or community liaisons who are called upon to help in various areas. The entire community system should be reviewed." Oumar Mallé Samb would still like to evaluate all of these options through a new research project to obtain solid data and strong cases. "The best result could then be applied nationwide," he says.
For the time being, empowerment through income-generating activities seems to offer good results, and Rosalie Diop pleads for this formula to become more widespread. "A salary would jeopardize the existence of the Bajenu Gox: by losing their volunteer status, they would lose their flexibility and would no longer be able to manage their schedule as they wish. There is a risk of loss of trust from the public, who will no longer see them as disinterested women, but as other health professionals. Finally, we must not forget that the state does not have the means to pay these women!" she argues.
Fighting the pandemic
Despite these advances, the network of godmothers remains fragile. Due to changes in the research team, the project was put on hold for six months. The break coincided with the withdrawal of the facilitators in charge of supervising the associations. Although this was planned, the interruption was abrupt: activities were greatly reduced and data collection stopped. "If Bajenu Gox are left to their own devices, they quickly abandon their activity," reports research assistant Fatou Kebe.
Especially since others often call on them because of the respect they enjoy among the population. There are, of course, the many NGOs that hire them for duties that are often paid. But there are also some politicians who do not hesitate to "divert" them from their health activities, especially during election periods, for example...
Relaunching in January 2020 was difficult. Then COVID-19 came along, changing the parameters and extending the project by three months. While the information sessions stopped at first, the Bajenu Gox relied on home visits. "With the virus, people stopped going to health facilities, they were afraid. Thanks to awareness-raising during home visits with reinforced measures, they have gradually returned," says Dieynaba Niang, vice-president of the Kaolack Bajenu Gox.
Proof of their versatility, the Bajenu Gox have been involved in the fight against COVID-19, including interventions in schools or in markets, making and distributing masks in Louga, or a partnership between the Parcelles Assainies association and Doctors Without Borders to raise awareness and avoid stigmatizing the sick... Once again, these community leaders have shown the extent to which they play a crucial role in public health in Senegal. So much so that now "all women want to become Bajenu Gox!" jokes Rouby Ba, a neighbourhood godmother in Diaoulé.
Opening this article: Photographed before the pandemic, these Bajenu Gox hold an information session, one of their key activities. During these sessions, they share their knowledge with the women of their community.
The original French version of this article was published in the November 2020 issue of Québec Science.