In Nigeria and Tanzania, Simulation Training Is Changing How Birth Emergencies Are Managed
On a Friday morning in Dawaki, Gombe State, Saleha, a mother of seven, was sitting outside her home when her waters broke. She had no labour pains or contractions. At the nearest health facility, she was advised to use a sanitary pad to reduce the risk of infection and to return when contractions began.
But the contractions did not arrive. By Sunday, she was still leaking fluid and becoming increasingly worried about herself and her unborn baby. Saleha and her husband went to the state specialist hospital in Gombe, hoping she would be assessed promptly and, if needed, admitted for an emergency caesarean section. Instead, they were told no doctor was available. “We were shocked,” she recalled.
After days of uncertainty and moving between facilities, Saleha finally delivered at another hospital. She lost a large amount of blood and needed three pints of blood. The experience changed her view of danger in pregnancy. “Now, if I feel even mild pain, I rush to the hospital,” she said
Nigeria’s maternal health crisis is shaped by both timely access to health facilities and the quality of care women receive once they arrive. The 2023-24 Nigeria Demographic and Health Survey shows that only 43% of births take place in health facilities, and just 46% are attended by a skilled health professional, such as a midwife or doctor. This means that more than half of Nigerian women still give birth without the support needed to identify and manage life-threatening complications.
For women who develop complications, survival may depend on how quickly the health team recognises the danger signs of pregnancy early enough and whether they have the skills and equipment to respond within minutes.
In Manyara Region, Tanzania, 29-year-old Fatuma arrived at Babati District Hospital to give birth to her second child with a different kind of fear. Her first delivery, three years earlier, had been traumatic with prolonged labour, minimal support, and a newborn who narrowly survived. “I was scared it would happen again,” she recalled.
This time, Fatuma met a team that had been trained through the Safer Births Bundle of Care (SBBC), an evidence-based programme that combines frequent simulation practice, teamwork, clinical tools, mentorship, and quality improvement to help health workers manage childbirth emergencies.
“When I arrived, I was welcomed warmly. The nurses told me not to worry, that they were trained to handle complications,” she explained. When she began bleeding heavily, the team moved quickly. “They acted quickly and confidently. One nurse held my hand and kept whispering that I would be fine,” Fatuma recounted. Moments later, her baby girl was born safely. “It was a miracle,” she said tearfully. “Without that team and what they learned from SBBC, I might not have survived. I pray for them every day, may they continue their good work.”
What changes when health workers practise emergencies before they happen
SBBC is more than a one-off training programme; it was developed through the Safer Births Consortium, which offers a bundle of clinical tools, low-dose high-frequency simulation training, mentorship, data utilisation, continuous quality improvement, and sustainability planning.
Its purpose is to help maternity teams prepare for the emergencies that most often cause maternal and newborn mortality. The SBBC programme was designed to reduce maternal and newborn deaths in low-resource settings, primarily implemented in Tanzania and now in Nigeria.
In Tanzania, the SBBC was implemented in Manyara, Shinyanga, and Morogoro regions and has delivered notable results, including 30 facilitation sessions that trained and mentored hundreds of healthcare providers, improved care for over 300,000 mother–baby pairs, a 75% reduction in maternal deaths in participating facilities, an 18% decline in perinatal deaths, a 40% reduction in deaths within 24 hours of birth, and a 16% reduction in deaths within seven days postpartum.
In Nigeria, SBBC is being tested in two northeastern states where the burden of maternal and newborn deaths remains high. Implementation began in January 2025, with the Clinton Health Access Initiative (CHAI) supporting Gombe State and Norwegian Church Aid supporting Borno State, in partnership with state health authorities.
Asmau Mohammed Bello, a mother of four from Tudun Wada in Gombe State, sharing her experience of how the improved maternal care and new monitoring equipment at Town Maternity Hospital made her delivery experience memorable.
Asmau Mohammed Bello, a mother of four from Tudun Wada in Gombe State, sharing her experience of how the improved maternal care and new monitoring equipment at Town Maternity Hospital made her delivery experience memorable.
A set of maternal and newborn care training mannequins—MamaBirthie, MamaNatalie, and Mama-U—the tools used to train health workers on safe delivery practices during emergency obstetric care.
A set of maternal and newborn care training mannequins—MamaBirthie, MamaNatalie, and Mama-U—the tools used to train health workers on safe delivery practices during emergency obstetric care.
Professor Baba Mallam Gana, former Commissioner of Health and Human Services in Borno State, stated that the initiative to introduce SBBC arose from a broader discussion among health commissioners in Nigeria’s northeast. In February 2024, a few months after taking office, he hosted health commissioners from Bauchi, Taraba, Adamawa, Gombe, and Yobe in Maiduguri to explore practical measures to decrease maternal deaths in the subregion.
At that meeting, Laerdal Global Health presented evidence from Tanzania, where SBBC had demonstrated strong results in reducing maternal and newborn deaths. After further consultation with Governor Babagana Umara Zulum, Gana advocated for the programme to be introduced in Borno. The Norwegian government later agreed to support a pilot in selected facilities.
In Gombe, implementation began in January 2025 across 11 pilot facilities. CHAI says more than 100 health workers have been trained. At Town Maternity PHC in Dawaki, which handles about 190 to 198 deliveries a month, staff say the programme has helped reduce unnecessary referrals.
“Before the training, we referred at least 22 cases monthly because we were not equipped to manage them,” said Zainab Umar Chiroma, the facility manager. “Now we can manage more complications here successfully.”
‘We have resuscitated many babies’
SBBC is built around four linked components: clinical innovations· training innovations· continuous quality improvement. sustainability
Its clinical innovations provide frontline health workers with low-cost tools to monitor labour, assess newborns, and respond during emergencies. These are supported by training innovations, particularly low-dose, high-frequency simulation exercises that develop skills, confidence, teamwork, and quicker emergency responses.
The model is strengthened through continuous quality improvement, where facility teams use local data to identify gaps, monitor progress, and tailor training to the real needs of maternity units. Its focus on sustainability promotes local skills and facility systems, creating a pathway for expansion, institutionalisation, and lasting impact.
In Borno State, the NCA created a training corner in each clinic that provides tools for low-dose high-frequency (LDHF) training. Each time a healthcare worker trains, it records how long the person has trained each day, making it easy to track. The training corners situated close to the labour and delivery wards are equipped with learning tablets, Wi-Fi, and mannequins for training. On the learning tablets, there are simulations for managing the third stage of labour, resuscitating the baby, and managing obstructive labour, among others.
“The mannequins are like real-life human beings. If you improve your skills, you will be more efficient. They do the training every day, and every nurse in the facility knows how to use the training tools,” Rita Danjuma, a Maternal and Newborn Care officer at NCA Nigeria, noted. “When a staff member does not participate in the training, it reflects on the dashboard too.”
According to Maimuna Bitrus Agyigra, the head of the Labour Room of Gwange PHC in Borno, this initiative has improved their work. “The day we started using it, I said, ‘Oh my God, maybe we have been [proclaiming babies dead] before exploring all resuscitation options.’
“Before, when a baby is born, and there is no pulse, [we assume] there is no sign of life in the baby, we say this is a dead baby. But now that we have NeoBeat [for rapid heart rate assessment] and we put it immediately on the chest of the baby after birth, and it picks up the faint heartbeat, and it encourages us to start resuscitating the baby,” she explained. “We have resuscitated many babies.”
A healthcare worker demonstrates the use of a suction device during a simulated maternal and newborn demonstration to clear mucus from a newborn’s airway and support safe breathing immediately after birth.
A healthcare worker demonstrates the use of a suction device during a simulated maternal and newborn demonstration to clear mucus from a newborn’s airway and support safe breathing immediately after birth.
A healthcare worker demonstrates the use of a suction device during a simulated maternal and newborn demonstration to clear mucus from a newborn’s airway and support safe breathing immediately after birth.
A healthcare worker demonstrates the use of a suction device during a simulated maternal and newborn demonstration to clear mucus from a newborn’s airway and support safe breathing immediately after birth.
In Gombe, midwives gather around life-like mannequins called NeoNatalie and MamaNatalie, simulating birth emergencies ranging from postpartum haemorrhage to neonatal asphyxia. “Every morning when we come to work, we practise resuscitation on the model,” Hauwa Jibril, a nurse-midwife at Town Maternity PHC, said.
In Tanzania, the use of advanced clinical tools has enabled faster and more accurate decision-making. Devices such as Moyo enable real-time foetal heart rate monitoring, while NeoBeat helps assess newborn viability immediately after delivery.
For the programme's sustainability, there are champions and mentors who are trained midwives and nurses from each facility that is carrying out the programme. Even when the partner organisations are no longer present, the knowledge remains with the staff at these facilities.
Hauwa Jubril, the SSBC champion at the Town Maternity Hospital, Gombe performs a simulated neonatal resuscitation on a mannequin using specialised equipment designed to help babies experiencing breathing difficulties.
Hauwa Jubril, the SSBC champion at the Town Maternity Hospital, Gombe performs a simulated neonatal resuscitation on a mannequin using specialised equipment designed to help babies experiencing breathing difficulties.
The promise is clear. The scale-up question is harder.
In Gombe, despite promising early results, scaling the intervention across the state’s more than 1,000 health facilities will require overcoming substantial barriers, with funding remaining the largest constraint to expanding an evidence-based programme that is already saving lives.
Although there are plans to expand the programme to 41 additional facilities, CHAI noted that no dedicated funding has yet been secured. In Tanzania, government ownership was central to scaling the intervention, pointing to the importance of similar commitment and investment in Gombe and other states.
Zainab, the facility manager at Town Maternity PHC, also explained that human resource turnover threatens sustainability. At the facility, only one of the three original SBBC champions who were trained remains. “We need more healthcare workers trained, but we do our best to cascade the knowledge down to all the staff.”
Infrastructure constraints persist, too. Poor internet connectivity affects digital data uploads, while referral transport remains unreliable in some facilities. Still, programme implementers say the model’s integration into government systems offers hope for sustainability. “The government has been involved from the start,” Zainab said. “What remains is to institutionalise it fully and scale gradually.”
In Borno, Professor Gana said it was challenging for them to change people's behaviour when they launched the programme, as people had had bad experiences with some healthcare workers who showed no respect or empathy for patients. “These were some attitudes that we needed to overcome.”
Another challenge in Borno is that, so far, SBBC training only takes place in six facilities in Maiduguri, the state capital. The programme is yet to be scaled up to cover the over 170 health care facilities in the state.
By Penelope Kim
Beyond clinical outcomes, providers say the intervention is helping to rebuild trust. Saleha now encourages women in her community to attend Town Maternity for antenatal care and delivery. “I tell women they should go [to the health facility],” she said. “Things are different now.”
That word-of-mouth trust is important. In communities where women recall neglect, disrespect or delays, a single safe delivery can change how families feel about the health system. However, trust cannot rely solely on individual goodwill.
If SBBC is to transition from pilot to full system, governments must fund it, integrate it into pre-service and in-service training, protect trained staff from constant redeployment, strengthen referral transport, and ensure that maternity units have the blood, medicines, power, internet, and personnel needed to operate.
For mothers like Saleha and Fatuma, survival can depend on the first few minutes of an emergency. For Nigeria’s health system, the lesson is equally urgent: nurses and midwives cannot save lives through training alone; they also need the equipment, supportive structures, and systems that enable them to use their skills when and where it matters most.
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