In West Africa, and especially in Mali, it is customary to go door-to-door when multiples (twins, triplets, etc.) are born, collecting support from neighbors. The birth of multiples can be a significant challenge for families with limited resources. Through this porte en porte tradition, communities provide tangible support to families in need, but it is also a sign of solidarity and social cohesion. Indeed, this custom is also often followed even by families with multiples who are not in need, in which case it is said to ensure that the children will live a long life.
Bintou migrated to Bamako about eight years ago, settling in Sotuba, a peri-urban community in Bamako’s Commune I. She and her husband separated when she was 3 months pregnant with her twins, so she decided to leave her village, along with her three other children. A move to Bamako gave her a better chance of earning an income that would allow her to support all her children on her own.
When she arrived in Bamako, things did not go as she had imagined and she had difficulty finding a place to live. She stayed with a friend throughout her pregnancy, and though her friend didn’t have much, she took care of Bintou until she gave birth. After her twins arrived, Bintou did not want to be a burden, so she and her five children settled in a home that was unfinished. That’s when she began to go porte en porte with her twins.
But as the twins grew, Bintou decided to start selling earrings to make her living. Her friend encouraged her to join a Mali Health savings group in order to get the funds to start her project. So she did. Then Bintou was able to take a loan from her group to purchase what she needed, and started selling. She walks throughout her community each day, selling earrings and other items that can be difficult to find in her community, like toothbrushes and toothpaste, from a large tray that she made.
Now age 7, the twins are doing well and are enrolled in school. For the past year, Mali Health has been working with mothers like Bintou to ensure that the interruption caused by the pandemic does not push families further into poverty, or pose an additional risk to their health. Bintou received support to grow her business, and she has been able to expand into selling a wider variety of items. In the future, her goal is to move her small business into a shop of her own.
It’s a Tuesday afternoon and the monthly SHARE group meeting in Sotuba is about to get started.
SHARE is our special savings program for pregnant women. At each meeting, women not only save funds for their maternal care and delivery, they also receive maternal health information, as well as sharing and receiving plenty of support. Everyone is welcomed warmly; there are plenty of chairs waiting and you can settle right into one and join the circle.
The meeting starts with the group’s facilitator sharing greetings and introductions. Today, the midwife from the Sotuba health center joins the meeting, as she often does, as well as the president of the ASACO, the community health association. The president is here to get to know the needs of women in her community and make sure the health center is responding to them. You see a few other women from the community walk over to join the circle too, just to hear the health information.
You notice that a few of the women have newborns and have already given birth. The women who participate in SHARE are at different stages of their pregnancy and the topic for discussion changes each month. The group facilitator reminds them of last month’s discussion and then she introduces the subject for this month. Because a few women are due soon, today the midwife walks women through what to expect during delivery at the health center.
She stresses the importance of planning for delivery early, advising women to think through all the details. She encourages them to choose the person who will accompany them to the health center, bring the funds they have been saving and their Mali Health card, bring at least five cotton cloths for the baby, bring soap to wash, and bring clothes for the baby and themselves to go home in. Throughout the conversation, women ask questions and the midwife occasionally stops to make sure everyone understands what to expect. She invites women who recently gave birth to share their experiences. She asks other women about their birth plans and questions they have about their preparations.
The midwife from the Sotuba health center explains what to expect when women arrive at the health center for delivery
You can feel the relaxed and friendly atmosphere in the group. Even when the presentation concludes, the group continues to chat and those who have already given birth share stories and advice. One of the women is pregnant with her first child and she seems a bit scared after listening one of the others talk about a more challenging delivery. Soon, the whole group notices her discomfort and begins to console and encourage her. She still has a few more months to prepare for her own delivery.
The purpose of the group is not just to ensure they have information about their pregnancies and make sure they are prepared financially, building relationships is just as important. Women in SHARE value the connections they make with one another and express their desire to support other mothers in their neighborhood. There is an openness among them here in this group that is unique; they don’t have many opportunities to talk with other women about their health, children, and lives. After their shared experience, they tell you how they feel like sisters.
Perhaps the most important relationship they build is with the midwife, which helps them build the trust they need to deliver at the health center with her help. The monthly talks provide a safe space to ask questions and get all the information they would not otherwise have, which also builds their confidence. Women note that their connection with her feels more like that of a trusted friend.
At the end of their meeting, you notice that saying goodbye seems to be the hardest part. Women linger and chat, checking in with those who gave birth, asking about someone who stayed home today. They all must get home to continue with their day’s chores, but they are soaking up every moment, until they meet again next month.
On Wednesday 10 July, Mali Health was honored by the Sotuba community in recognition of our partnership, and the impact it has had on improving community health. While we were the ones being recognized, for us, this event was actually a chance to celebrate the strong leadership in Sotuba, and the community’s investment and ownership of their health, and health system.
Sotuba is a peri-urban community on the eastern side of Bamako and Mali Health collaborates with the health center (CSCom) to improve healthcare quality and governance, as well as supporting community health workers and women’s health savings groups there.
The celebration featured staff from Mali Health, members of the community, and the president of Sotuba’s ASACO (Association de Santé Communautaire), the organization made of community members that oversees the health center. The ASACO serves as a bridge between the health center and the surrounding community, linking the organization and the people.
The ASACO has a key role in helping to improve the health of the community. When a community has an organized and efficient ASACO, the CSCom’s work is tailored to the specific needs of the people it serves, the CSCom becomes more responsive, and the amount of women and children seeking care at the health center increases.
Sotuba is one of the smallest communities with whom Mali Health collaborates. When the partnership began, the ASACO had no structure or organization and it was unclear to the community and the health center what exactly the role of the ASACO was. Unfortunately, most low-resource communities in Mali face the same challenge and one of the most important pillars of the community health system often is not able to fulfill its role of ensuring strong management, accountability and community participation in health centers.
Today, Sotuba’s ASACO is an active group of community members who are fulfilling that essential role – and they are seeing impressive results. On a measurement scale we use for transparency and accountability, Sotuba went from being one of the lowest-scoring partners to one of the highest. Sotuba’s patient satisfaction scores are consistently among the highest, over 95%, and the rates of pregnant women returning to deliver at the CSCom are the highest of any of our partners – sometimes reaching 100%.
As one of Mali Health’s first partners to implement, test, and refine our participatory quality improvement (QI) approach, their hard work speaks for itself. For several years, a QI coach has provided technical support and coaching to a QI team at the Sotuba CSCom and we are now in the process of turning the QI program over to that team, so that they can continue serving their community at this high level.
To support the efforts of the health center and extend the impact of improvements in quality, Mali Health has provided community health workers and free or subsidized healthcare to children and pregnant women with the least access. We also help women in Sotuba access more financial resources that can help them improve their family’s health. By addressing preventive healthcare, hygiene, and budgeting, these strategies aim to advance health in Sotuba by helping women gain more knowledge about their children’s health and increase their ability to act on it.
A mother and savings group member who attended the celebration shared her experience:
Two times a month, Mali Health makes contact with us parents, to see the evolution of the state of health of the children. They are really there for us; we are really grateful. They educate us about the nutrition of our children and hygiene. The savings funds that Mali Health helped us set up helps us a lot to provide hygiene products such as our soaps and other cleaners. I’m so grateful that I have tears in my eyes about Mali Health.
Mali Health’s overarching goal is to support the Sotuba community to improve access to healthcare; the partnership is rooted in the community’s desire for change. Although there is more work to be done, this celebration represented an important milestone and the core of what makes Mali Health’s approach different. While Mali Health can give support to the health center, mothers and community members to improve health and to make change, it is up to them to decide whether to adopt strategies, act on information, and to take ownership of those strategies to sustain that change in the long term.
As the president of the ASACO described it, to the community, Mali Health represents the idea that a different future is possible, and within their reach. During his acknowledgement, the president reflected:
I remember a story that was told to me by one of my teachers: a little boy from a small village became a doctor and became a source of hope for his entire community. This little boy reminds me of Mali Health which has become the source of hope for our community.
Members of the Sotuba community have seen the change they are able to make to improve the health of mothers and children. While Mali Health remains so grateful for their partnership, and their gracious efforts to recognize what our partnership has achieved, we are most excited by the real steps forward that community members in Sotuba are taking to actively participate and take ownership of their health system and its future.
Every community with whom we work will always have our support, but our role is to strengthen their ability to manage and improve health in their communities, so that they can take the lead.
When they are the ones who start giving us the certificates and the chiwaras – then we know we’re all doing something right.
