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‘Reduce maternal mortality by three quarters by 2015’
ARTICLE IN PRESS Midwifery (2005) 21, 201–203
www.elsevier.com/locate/midw
EDITORIAL
‘Reduce maternal mortality by three quarters by 2015’ The title of this editorial comes from the internationally recognised Millennium Development Goals (Haines and Cassels, 2004; Nullis-Kapp, 2004). On its 60th birthday the United Nations has reported that it does not think the international community will achieve the goal of reducing maternal mortality by three quarters, neither do I. My reasons for saying this are that I have just returned from a working visit to Nigeria. I was there to see one of my PhD students, who is desperate to stop her ‘sisters’ dying in childbirth. There are no accurate statistics available in Nigeria for maternal mortality. Recently a study was reported in a local paper that stated that in Lagos the maternal death ratio was 3,380 per 100,000 births and in another urban area (Kano) it was 7,523. However, these figures are based on women who got to the hospital. My student is undertaking a community study using the Sisterhood Method (Graham et al., 1989). Basically she is ‘knocking on doors’ and asking the occupants how many adult sisters they had, how many have died and how many died in pregnancy, childbirth or the first six weeks after birth. I received a distraught email at the beginning of the pilot study—during the first day she and her data collectors had found five maternal deaths in two streets. None of them appeared in any local statistics. One was ‘sort of’ known to the local health centre. The woman had been referred by a midwife to the nearest hospital, I think for prolonged labour. On the way to the hospital the woman and her husband met a friend who, on hearing where they were going and why, recommended that they go to the Traditional Healer. The reasons for this recommendation were that the friend had been treated successfully by the Traditional Healer when she experienced problems in childbirth and the (labouring) woman ‘would not want to cause her husband unnecessary expense,
would she?’ When the husband realised that the Traditional Healer was not being successful he decided not to take the woman to hospital, because he thought it was too late, but instead took her back to the health centre. The midwife refused to accept the woman, because she, the midwife, had already referred her to the hospital. The woman died in the back of the car. So not only did this woman die in childbirth, but she did not even have a dignified death. During my visit my student took me to meet the Kings in the villages where she has been data collecting. My student had had to ask the Kings for permission to undertake the data collection in their villages. I was told by the King and his chiefs in one village that before my student went to visit them they had never seen a health carer and there was no health centre in a village with a population of 24,089. They told us where the nearest health centre with maternity facilities was and advised us to visit it, they thought there were four midwives for staff. We found the centre and found only a minimally trained health worker on duty. Her training would not have fulfilled the World Health Organization (WHO) definition of a ‘skilled birth attendant’ (WHO, 2005). She told us that there was a midwife on duty 8am to 2pm Monday to Friday, but she did not know why the midwife was not there that day (a week day). We were shown the delivery register and found that the midwife’s name was only by one delivery record in the last three months. This led us to conclude that the midwife’s absence was not unusual. We were also shown the register where the names of the women who had ‘booked’ for antenatal care were recorded. There was a discrepancy between the number receiving antenatal care and the number giving birth in the centre. Far fewer came for care in labour and I was informed that this was not
0266-6138/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2005.06.002
ARTICLE IN PRESS 202
EDITORIAL
unusual in this area. The health worker showed us around. The labour room was filthy with dust everywhere and the mosquito nets on the windows were broken. The facilities in the ‘lying-in ward’ were no better. The mattress covers were torn so that the stuffing was coming out, the bed frames were old, the paint was peeling off and the cots had foam mattresses that were not covered with waterproof material. There was electricity, but constant power failures mean relying on Kerosene lamps most of the time. There was no clean water in the centre, rain water was collected and kept in a container that was supposed to have been used as a rubbish bin. I am not surprised that the women did not attend for care in those surroundings and it must have been demoralising for the midwife to work there. There is possibly another reason why women did not attend for care. I was constantly told that antenatal care and care in labour were free. But it was not completely free because women were required to bring with them a list of items that were considered necessary (see Box 1). The cost of these items are considerable for those with limited financial resources, as most of those who would have used that facility came within that definition. We went to another village and visited another health centre. Again no midwives were present, but we were told that this was because the local government had assigned them to another centre and their replacements had not yet arrived. Only about four women a month were registering for antenatal care at this centre, despite the fact that
Box 1 Items women were required to bring to the Health centre when they were in labour. Vulval pads Gloves Matches Blade Omo (washing powder) Kerosene Ororo (nut oil)* Cord clip Dettol Toilet soap Toilet roll Cotton wool Spirit Glucose Candles Jik (cleaning fluid) Mucus extractor *Used to clean the baby.
2 packets 1 1 packet 1 1 packet 1 2 gallon 1 2 bottle 1 1 2 2 1 roll 1 bottle 1 bottle 2 1 bottle
there was a large population in the area and it was the only health centre in the vicinity. Again, the number of deliveries they had did not match the number of women receiving antenatal care and no baby had been born in the centre since April (I was visiting at the end of June). I asked about care in labour and recording of observations. I could gain no sensible answer and the partogram was nowhere to be seen. At this centre the labour ward was cleaner than the first, but the ‘delivery table’ appeared to be a very large dining table covered in waterproof padding. It had wobbly legs so the women must have felt very unstable when asked to stay on it. Whilst the labour room was relatively clean the lying-in area was dirty with again torn mattresses. At this centre we met a, frustrated, Primary Health Care Doctor. It had taken him two years to obtain one month’s supply of basic medicines and inoculations. They were planning to commence the inoculation programme in July, but they had no functioning vehicle so that they could visit the surrounding villages. They had a government provided, vehicle that but 18 months ago it had developed a mechanical problem and had not been repaired. To repair it now would obviously take considerably more resources than if it had been repaired when it first broke down. We tried to visit another village where there was no health centre or worker. However, we had to abandon the attempt because there had been a heavy rain fall and it was impossible to get across the river. If we could not get into the village, then if a pregnant or childbearing woman needed assistance she would not have been able to get to the health centre that we had visited. Whilst in Nigeria I participated in a workshop on Safe Motherhood. The workshop was designed for midwives and 66 were invited, 96 attended, but not all were midwives, other types of health-care workers attended because they, and the midwives, want to prevent maternal mortality. The midwives know how to stop women dying, but they do not have the resources they need. We heard of a midwife being responsible for the antenatal care of 1,000 women per year, we heard that women do not attend the health facilities in labour, as noted above understandable when the facilities are so poor. The midwives complained of lack of transport to transfer women and the fact that women do not go to the hospital when advised to. As I was informed that women have to pay for all their drugs and theatre packs at the hospital it is not surprising that families with limited resources do not accept the advice. I was told that there had been occasions when midwives admitted women to hospital despite their lack of money and had told the women
ARTICLE IN PRESS EDITORIAL that they could pay after they were delivered. These women had not returned with the money and the hospital had taken the money out of the midwives’ salaries. I was also told of a woman who could not pay for her theatre pack (cost about £26), so was left to die. The WHO (2005) comment on the need that midwives must have good first level and continuing education, and almost 15 years ago we published a paper suggesting that educated midwives were confident midwives (Kwast and Bentley, 1991). I visited a school of midwifery where there are 50 students each year. They have a very generous teacher-student ratio as the Nigerian Nursing and Midwifery Council require one teacher to six students. However, their library resources were pitiful. The library was padlocked. When we went inside I could not see any recent publications. All that were there were old textbooks, no journals. So how can these students become acquainted with the most recent evidence on which to base their practice. It also appeared to me that the library was not used much. So what is the answer? Well, until my student has completed her data collection and undertaken the analysis it will not be possible to provide the accurate maternal mortality ratio for that particular area. It is very evident that poverty is the underlying problem. But it is also evident that there is also an absence of political will to try and alleviate the situation. At the workshop the previous Commissioner for Health gave a very good review of the literature on maternal mortality,
203 including the direct and indirect causes. There was a definite hint that women were to blame for not attending for care. There was no recognition that considering the facilities that was understandable. There was no recognition that the transport facilities were inadequate. There was no recognition that midwives working in substandard conditions become frustrated and demoralised. Until those in political power recognise and develop the political will to improve conditions women will continue to die in pregnancy and childbirth.
References Graham, W., William, B., Snow, R., 1989. Estimating maternal mortality: the Sisterhood method. Studies in Family Planning 28, 132–142. Haines, A., Cassels, A., 2004. Can the Millennium Development Goals be attained? British Medical Journal 329, 394–397. Kwast, B., Bentley, J., 1991. Introducing confident midwives: midwifery education—action for Safe Motherhood. Midwifery 7 (1), 8–19. Nullis-Kapp, C., 2004. The knowledge is there to achieve development goals, but is the will? Bulletin of the World Health Organization 82, 804–805. World Health Organization, 2005. Make every mother and child count, The World Health Report 2005. World Health Organization, Geneva.
Ann Thomson University of Manchester, Coupland III Building, Oxford Road, Manchester M13 9PT, UK E-mail address: [email protected]
www.elsevier.com/locate/midw
EDITORIAL
‘Reduce maternal mortality by three quarters by 2015’ The title of this editorial comes from the internationally recognised Millennium Development Goals (Haines and Cassels, 2004; Nullis-Kapp, 2004). On its 60th birthday the United Nations has reported that it does not think the international community will achieve the goal of reducing maternal mortality by three quarters, neither do I. My reasons for saying this are that I have just returned from a working visit to Nigeria. I was there to see one of my PhD students, who is desperate to stop her ‘sisters’ dying in childbirth. There are no accurate statistics available in Nigeria for maternal mortality. Recently a study was reported in a local paper that stated that in Lagos the maternal death ratio was 3,380 per 100,000 births and in another urban area (Kano) it was 7,523. However, these figures are based on women who got to the hospital. My student is undertaking a community study using the Sisterhood Method (Graham et al., 1989). Basically she is ‘knocking on doors’ and asking the occupants how many adult sisters they had, how many have died and how many died in pregnancy, childbirth or the first six weeks after birth. I received a distraught email at the beginning of the pilot study—during the first day she and her data collectors had found five maternal deaths in two streets. None of them appeared in any local statistics. One was ‘sort of’ known to the local health centre. The woman had been referred by a midwife to the nearest hospital, I think for prolonged labour. On the way to the hospital the woman and her husband met a friend who, on hearing where they were going and why, recommended that they go to the Traditional Healer. The reasons for this recommendation were that the friend had been treated successfully by the Traditional Healer when she experienced problems in childbirth and the (labouring) woman ‘would not want to cause her husband unnecessary expense,
would she?’ When the husband realised that the Traditional Healer was not being successful he decided not to take the woman to hospital, because he thought it was too late, but instead took her back to the health centre. The midwife refused to accept the woman, because she, the midwife, had already referred her to the hospital. The woman died in the back of the car. So not only did this woman die in childbirth, but she did not even have a dignified death. During my visit my student took me to meet the Kings in the villages where she has been data collecting. My student had had to ask the Kings for permission to undertake the data collection in their villages. I was told by the King and his chiefs in one village that before my student went to visit them they had never seen a health carer and there was no health centre in a village with a population of 24,089. They told us where the nearest health centre with maternity facilities was and advised us to visit it, they thought there were four midwives for staff. We found the centre and found only a minimally trained health worker on duty. Her training would not have fulfilled the World Health Organization (WHO) definition of a ‘skilled birth attendant’ (WHO, 2005). She told us that there was a midwife on duty 8am to 2pm Monday to Friday, but she did not know why the midwife was not there that day (a week day). We were shown the delivery register and found that the midwife’s name was only by one delivery record in the last three months. This led us to conclude that the midwife’s absence was not unusual. We were also shown the register where the names of the women who had ‘booked’ for antenatal care were recorded. There was a discrepancy between the number receiving antenatal care and the number giving birth in the centre. Far fewer came for care in labour and I was informed that this was not
0266-6138/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2005.06.002
ARTICLE IN PRESS 202
EDITORIAL
unusual in this area. The health worker showed us around. The labour room was filthy with dust everywhere and the mosquito nets on the windows were broken. The facilities in the ‘lying-in ward’ were no better. The mattress covers were torn so that the stuffing was coming out, the bed frames were old, the paint was peeling off and the cots had foam mattresses that were not covered with waterproof material. There was electricity, but constant power failures mean relying on Kerosene lamps most of the time. There was no clean water in the centre, rain water was collected and kept in a container that was supposed to have been used as a rubbish bin. I am not surprised that the women did not attend for care in those surroundings and it must have been demoralising for the midwife to work there. There is possibly another reason why women did not attend for care. I was constantly told that antenatal care and care in labour were free. But it was not completely free because women were required to bring with them a list of items that were considered necessary (see Box 1). The cost of these items are considerable for those with limited financial resources, as most of those who would have used that facility came within that definition. We went to another village and visited another health centre. Again no midwives were present, but we were told that this was because the local government had assigned them to another centre and their replacements had not yet arrived. Only about four women a month were registering for antenatal care at this centre, despite the fact that
Box 1 Items women were required to bring to the Health centre when they were in labour. Vulval pads Gloves Matches Blade Omo (washing powder) Kerosene Ororo (nut oil)* Cord clip Dettol Toilet soap Toilet roll Cotton wool Spirit Glucose Candles Jik (cleaning fluid) Mucus extractor *Used to clean the baby.
2 packets 1 1 packet 1 1 packet 1 2 gallon 1 2 bottle 1 1 2 2 1 roll 1 bottle 1 bottle 2 1 bottle
there was a large population in the area and it was the only health centre in the vicinity. Again, the number of deliveries they had did not match the number of women receiving antenatal care and no baby had been born in the centre since April (I was visiting at the end of June). I asked about care in labour and recording of observations. I could gain no sensible answer and the partogram was nowhere to be seen. At this centre the labour ward was cleaner than the first, but the ‘delivery table’ appeared to be a very large dining table covered in waterproof padding. It had wobbly legs so the women must have felt very unstable when asked to stay on it. Whilst the labour room was relatively clean the lying-in area was dirty with again torn mattresses. At this centre we met a, frustrated, Primary Health Care Doctor. It had taken him two years to obtain one month’s supply of basic medicines and inoculations. They were planning to commence the inoculation programme in July, but they had no functioning vehicle so that they could visit the surrounding villages. They had a government provided, vehicle that but 18 months ago it had developed a mechanical problem and had not been repaired. To repair it now would obviously take considerably more resources than if it had been repaired when it first broke down. We tried to visit another village where there was no health centre or worker. However, we had to abandon the attempt because there had been a heavy rain fall and it was impossible to get across the river. If we could not get into the village, then if a pregnant or childbearing woman needed assistance she would not have been able to get to the health centre that we had visited. Whilst in Nigeria I participated in a workshop on Safe Motherhood. The workshop was designed for midwives and 66 were invited, 96 attended, but not all were midwives, other types of health-care workers attended because they, and the midwives, want to prevent maternal mortality. The midwives know how to stop women dying, but they do not have the resources they need. We heard of a midwife being responsible for the antenatal care of 1,000 women per year, we heard that women do not attend the health facilities in labour, as noted above understandable when the facilities are so poor. The midwives complained of lack of transport to transfer women and the fact that women do not go to the hospital when advised to. As I was informed that women have to pay for all their drugs and theatre packs at the hospital it is not surprising that families with limited resources do not accept the advice. I was told that there had been occasions when midwives admitted women to hospital despite their lack of money and had told the women
ARTICLE IN PRESS EDITORIAL that they could pay after they were delivered. These women had not returned with the money and the hospital had taken the money out of the midwives’ salaries. I was also told of a woman who could not pay for her theatre pack (cost about £26), so was left to die. The WHO (2005) comment on the need that midwives must have good first level and continuing education, and almost 15 years ago we published a paper suggesting that educated midwives were confident midwives (Kwast and Bentley, 1991). I visited a school of midwifery where there are 50 students each year. They have a very generous teacher-student ratio as the Nigerian Nursing and Midwifery Council require one teacher to six students. However, their library resources were pitiful. The library was padlocked. When we went inside I could not see any recent publications. All that were there were old textbooks, no journals. So how can these students become acquainted with the most recent evidence on which to base their practice. It also appeared to me that the library was not used much. So what is the answer? Well, until my student has completed her data collection and undertaken the analysis it will not be possible to provide the accurate maternal mortality ratio for that particular area. It is very evident that poverty is the underlying problem. But it is also evident that there is also an absence of political will to try and alleviate the situation. At the workshop the previous Commissioner for Health gave a very good review of the literature on maternal mortality,
203 including the direct and indirect causes. There was a definite hint that women were to blame for not attending for care. There was no recognition that considering the facilities that was understandable. There was no recognition that the transport facilities were inadequate. There was no recognition that midwives working in substandard conditions become frustrated and demoralised. Until those in political power recognise and develop the political will to improve conditions women will continue to die in pregnancy and childbirth.
References Graham, W., William, B., Snow, R., 1989. Estimating maternal mortality: the Sisterhood method. Studies in Family Planning 28, 132–142. Haines, A., Cassels, A., 2004. Can the Millennium Development Goals be attained? British Medical Journal 329, 394–397. Kwast, B., Bentley, J., 1991. Introducing confident midwives: midwifery education—action for Safe Motherhood. Midwifery 7 (1), 8–19. Nullis-Kapp, C., 2004. The knowledge is there to achieve development goals, but is the will? Bulletin of the World Health Organization 82, 804–805. World Health Organization, 2005. Make every mother and child count, The World Health Report 2005. World Health Organization, Geneva.
Ann Thomson University of Manchester, Coupland III Building, Oxford Road, Manchester M13 9PT, UK E-mail address: [email protected]