Martha Jackson was sixteen when she became pregnant. Abandoned by her parents with no knowledge of maternal care, Hawa Smith, a Trained Traditional Midwife (TTM), became her guard.
“I was so scared and ashamed,” recalls Jackson, now a mother of a three-month-old girl in Goba’s Town, Todee District, Montserrado County. “But the midwife was always there to encourage me, ensure I took my medicine, and sleep under a mosquito net.”
With the midwife’s guidance, Jackson attended her prenatal visits, heeded the nurses’ instructions, and delivered her baby safely without complications. In Liberia, poverty and limited healthcare services put pregnant women at risk. In rural communities, TTMs like Smith are on the frontlines to support teenage mothers. Jackson, now seventeen, is one of the few beneficiaries of the support of TTMs.
Smith and her colleagues were recruited by the government after receiving basic training and earning a certificate to help the country meet the Sustainable Development Goal (SDG) of reducing the maternal death rate to less than 70 per 100,000 live births.
They were turned over to the community after completing training to identify danger signs in pregnancy, recommend referral, and ensure that Jackson and other women seek maternal care to avoid maternal and neonatal deaths. Liberia has made progress in reducing maternal deaths from 807 in 2003 to 652 in 2020, according to World Bank statistics.
Smith and her peers, 34 elderly women, are among the 3,500 who work 24 hours every day in rural communities like Goba’s town, which has deplorable roads and electricity issues. Night work for Smith and her peers is a tedious one. Torch lights and motorcycles are their only reliance. In cases where a motorcycle is not available, they must walk, navigating their way through bushes and terrible zones to get a pregnant woman in labor to the health center.
In Liberia, there is a strong restriction on home delivery. Violators are fined per amount agreed upon by communities. Traditional birth attendants (TBAs) were blamed for the country’s high maternal mortality rate after the war in 2003, prompting the government and partners to train Smith and her peers as TTMs. In Goba’s Town, if TTMs disregard the restriction, violators are fined 3,000 Liberian dollars.
They are assigned to government health centers to serve both remote communities (more than a one-hour walk or 5 km from a facility) and those within 5 km. In this role, Smith and her colleagues conduct house-to-house visits to ensure teenagers like Jackson adhere to their prenatal and postnatal care schedules. They also assist mothers with newborn care.
“My daughter, referring to the reporter, we are suffering,” she said. “At night, we are forced to take the pregnant woman to the health center, and the government can even feel sorry for us and put us on the payroll?”
She asks the government to compensate them for “risking their lives to save a life.”
In the Revised National Community Health Services Policy, TTMs are referred to as Community Health Volunteers (CHVs), with no commitment from the government on their salaries or compensation. Their services provided are free. Their compensation relied on programs implemented by donors through campaigns they participated in, such as immunization campaigns, mass Insecticide Treated Nets (ITNs) distribution or directly observed therapy short courses (DOTS).
Monetary and non-monetary mechanisms of motivation may be considered, determined by the donor with a specific daily disbursement of US$ 5 per day, not exceeding 10 days per month.
“The government has abandoned us,” said Garmai Sackie, another TTM. “This work is hard. We don’t get any pay. We want to be paid.”
The Ministry of Health acknowledged the contributions of TTMs. In an email, S. Olasford Wiah, Director of the Community Health Division, said TTMs are not provided any direct financial compensation from the government. However, the MOH, through its many partners (Americare, Plan International, Samaritan Purse, and UNFPA), is providing transportation for them for attending network meetings, as well as non-cash performance incentives such as lappa (wrapper) and other materials for following up and accompanying pregnant women for facility delivery.
“There is no plan to enroll TTMs onto the government payroll, at least for now,” he said.
Health centers and community leaders have partnered to compensate the midwives, though they see it as too little. Although the Goba Town clinic is free for the public, here upon delivery, the parents or families of pregnant women paid 1,500 Liberian dollars, which is given to the midwife as compensation, only if the delivery occurred at their assigned clinic. The midwife loses the money if the delivery is conducted at a different facility.
“Our TTMs are seeing this very little,” said Ayouba Konneh, secretary general of the Liberia Midwives Association. “Yes, because at the end of the day, people will come to the facility to have a safe delivery; they will not bring a dam,” he said.
He urged the government to revisit the health policy or pass laws that allow TTMs to get financial compensation. “We need intentional action from the government to incorporate TTMs in the budget.”
Antoinette Freeman, Officer in Charge, Goba Town Clinic, said there are 34 midwives assigned at the facility, including Smith. Their compensation is from delivery fees paid by the families and relatives and support from NGOs such as Plan International Liberia that provide financial support to midwives based on the referrals they do.
She said TTMs have complained that they want to be paid by the government and not through programs that do not last.
Belloh Nyenatoh, Community Health Technical Specialist, Plan International Liberia, said TTMs receive $50 for feeding and transportation for attending a meeting held once every six months.
TTMs also received incentives based on referrals—pregnant women they bring for their intermittent preventive treatment in pregnant women (IPTp) full doses—three doses. $1 per dose. “So, it is designed this way; if you refer to the IPTp one, we give you $1; if you refer to the IPTp two, we give you $2; and if you refer to the IPTp three, we give you $3. “So, depending on the number of referrals you do, you have an incentive apart from the $50.”
“So depending on the referral you do, then you will get incentives. Apart from the $50 you get for regular meetings for transportation and feeding,” she said.
Although there is no plan to put Smith and her colleagues on the payroll, Waih said through the National Community Health Program (NCHP) Policy 2025-2035, TTMs have been enlisted as one of the cadres of community health workers in a volunteering position.
