In the blog—Who is to blame for the Poor Health Workers Attitudes and how can we cure This Disease by Dr. Elizabeth Ekirapa-Kiracho—it was indicated that some women have opted to give birth at home rather than face the wrath of health workers.
This is true. Through the voices of community and health workers’ voices, I will share with you maternal and newborn challenges based on the experience from the implementation of a maternal and newborn care project in rural communities of Uganda.
Dr. Ekirapa-Kiracho pointed out health workers’ attitude as one of the reasons why women opt to give birth from home. Women are delivering from traditional birth attendants (TBAs) and actually from private clinics because they are given good care. This also came up from an interview with a mother who had delivered from a TBA. “I decided to deliver from the TBA, because she has a good care other than going to the government hospitals and suffer from there,” she said, adding that, the distance from her home to the TBAs is nearer so she doesn’t need to spend a lot on transport.
In the same blog, Dr. Ekirapa-Kiracho noted several circumstances that contribute to health workers having a poor attitude where one of the most common ones is a heavy workload. This is due to lack of health workers at the facility. Most of the facilities have one health worker who is in charge of providing maternal and newborn services. The same worker works day and night in attending to clinic patients, immunization, antenatal care, and deliveries. This was also pointed out in an interview with the health worker.
The first challenge we have is that we lack enough health workers. For example, in this facility the number of clients have increased but I am the only one midwife who works on the increased number. So it is a very big challenge for us because I need to rest and I also get problems.
As a result, there is no health worker to attend to the women who come at night. A woman who had delivered from the facility narrates,
When time for delivery reached, I went at 23:00 to the health facility but when I reached, there was no health worker to attend to me. So I delivered on myself from the veranda with the help of the caretaker. The health worker saw me in the morning when I had delivered. So, you tell us to deliver from the health facility, but who is there to attend to us? Is there any difference between me and someone who delivered from home?
In some facilities it is a nursing assistant (who is not a skilled worker) conducting deliveries. A health facility in-charge of one of the facility narrates,
Women are now being referred by the village health teams (VHTs) for maternal and newborn care services. The VHTs are sensitizing women on issues related to maternal and newborn services thus discouraged from delivering from the TBAs. The challenge we are having now is that the facility does not have a midwife. We are improvising by using the nursing assistant who is not trained to do that work.
Furthermore, there is always stock-outs of essential drugs and inadequate equipment for maternal and newborn care. Yet, to enable health workers to work effectively, there has to be an enabling environment that helps in ensuring the quality of maternal services at the health facilities.
You see we are lucky that our facility has electricity connection but the maternity has wiring problem. This problem has been there for almost two years. We no longer use the sterilizer, bulb syringe, and we do not have a weighing machine. We also don’t have security personnel for almost two years. Additionally, there is always stock out of drugs and other essential equipments needed for maternal and newborn care. For example we have not been having syphilis reagents for last 12 months.
Additionally, there is poor referral systems at both health facilities and communities. Yet, this is very important in reducing maternal and newborn deaths. A postpartum woman who lost her baby narrates,
When time for delivery reached, I went to the health center for delivery because it is where I was going for antenatal care. I reached the health center at 2:00 P.M. but was referred to the hospital at 3:00 A.M. Immediately I reached the hospital, the health workers found that they could not manage me and I was referred to the regional hospital. Unfortunately, the driver for the ambulance was not around, so it took time to get the vehicle to take me to where I was referred. The vehicle was got at 4:00 A.M. and we reached the regional hospital at 6:00 A.M. When I reached [the regional hospital], immediately I was put on the drip and a decision was made for the Caesarean. Unfortunately the baby died immediately after delivery.
As a result of the above—inadequate health workers, distance to the facilities, and poor referral systems—women decide to first seek services from the TBAs thus reaching the facilities when it is too late. An interview was conducted with the sister of the mother who died while delivering and she narrates:
When the time for delivery reached (immediately the labor started at 8:00 A.M.) we first went to the TBA who gave us local herbs. We spent some time there and at the end we decided to go to the health center III at around 7:00 P.M. When the health center III staff failed, they referred her to the hospital at 11:00 P.M. We reached the hospital late at night and the doctor opted for a Caesarean. After the operation, she bled too much and this resulted to her death.
Now based on the above voices from the community and the health workers, what are key critical areas need to be addressed? I pick four interdependent/interrelated areas:
- Put in place community referral transports and strengthen the facility referral transport
- Avail essential equipments and supplies needed for maternal and newborn services at the health facilities
- Recruit skilled maternal and newborn health workers
- Build the capacity of health workers
There is no shortcut, the above are very crucial for the success of any maternal and newborn care program in developing countries. What is your view?
This post was slightly edited from the original, which appeared on the blog for Knowledge Translation Network: Africa.