Not just Mother’s Matters

Project synopses:

NUFU - Maternal health care in sub-Saharan Africa

NOMA - Health and Information Systems

• Every year, over 10 million mothers and children die from mostly preventable causes.
• Every minute of every day, a woman dies needlessly during pregnancy or childbirth.
• Every three seconds, a child under the age of five dies.

BWAILA HOSPITAL:
“We don’t have much time. I’ll show you the hospital as it is now,” says Dr. Tarek Meguid, rushing out of the small library onto the courtyard of Bwaila Hospital. This notoriously overburdened maternity ward delivers the staggering number of 12 000 to 13 000 infants every year, an average of about 35 a day. As of April 2009, German obstetrician and gynaecologist Meguid is the only medical consultant working full time. He summarises his five years of service in the Malawian health care system this way:
“On good days I would say it’s a marvellous opportunity to change things for the better. On bad days it’s a never ending nightmare of human suffering and criminal human rights violations”.

NOT ENOUGH BEDS | Conditions at Bwaila HospitaL in Lilongwe are bad. These pregnant women are all waiting to give birth at the hospital. Photo: Arlette Olaerts

SERVING THE POOREST OF THE POOR
At the moment, Bwaila is a combination of district and central level maternity hospital.

“For our patients, this means that this is the only possibility they have in case of complications. They have no chance to go anywhere else,” says Dr. Meguid.

According to numbers from the Malawi Millennium Development Goals Report of 2008, an estimated 67 per cent of births in Malawi are now attended by skilled health personnel.

This is an improvement over the 1992 figure, when the percentage was about 55. The Millennium Development Goal (MDG) target, however, is that all women should have a qualified attendant present while giving birth. Malawi is unlikely to meet this goal by 2015.

In a lot of cases, expectant mothers who come to Bwaila are in the late stages of delivery, often to the point where it has turned into a struggle for pure survival.

The hospital’s former name; Bottom Hospital, as opposed to top hospital, gives a good indicator of its background and the people who are treated here. Patients are generally financially and politically weak.

“There are a lot of things that take some time to appreciate in a place like Bwaila Hospital. One of them is the degree of poverty under which a lot of our patients live, as well as the deprivation of all sorts of things, one of which is normal dignity. We serve the poorest of the poor”, says Dr Meguid.

THE SHOCKING FIGURES
The maternal mortality ratio (MMR) of a country or region is the number of deaths from pregnancy- or childbirth-related complications per 100 000 live births. Estimates made by the World Health Organization (WHO), published in The World Health Report in 2005, showed a staggering MMR of 1800 in Malawi in 2000.

“This should have been headline news not only in Malawi, but also in the major papers of the world: MMR in Malawi is 1 800 per 100 000 births! This kind of MMR is almost unbelievable and certainly unacceptable. More developed countries have MMRs of around 10, and most other countries in the region have ratios of about 200,” says Dr. Meguid.

THE WAITING ROOM | At ‘the old Bwaila’, there is not enough room for patients to bring anyone
to accompany them at labour, friends and family members wait outside the maternity ward. Photo: Kjersti Brown

According to him, the MMR is said to have been as high as 2 350 in medieval Europe. Research from the United States more than 20 years ago shows that the MMR in an American subpopulation where mothers refused any obstetric intervention during childbirth was at 872. The Malawian Government’s MDG Report of 2008 shows the same astonishing level of MMR in 2006. According to their figures, however, MMR in Malawi never rose as high as 1 800. They reported the official maternal mortality ratio in the country to be 1 120 in 2000, falling to 984 in 2004 and further to 807 in 2006.

Explanations for the alarming figures are complex. Perhaps the most obvious is the extreme shortage of trained medical staff. In 2005, when Malawi’s population was at about 12 million, there were only about 100 doctors and 2 000 nurses working in the health sector. In 2009, the population is estimated to be about 14 million.

“The overall number of medical staff might have gone up slightly, but not in the public sector. Most all university graduates leave government service for greener pastures abroad or in the private sector as soon as they qualify. But I’m confident it’s going to come. It has to, because they soon won’t be able to find other jobs,” says Meguid.

WHO, in its World Health Report of 2005 refers to confidential enquiries into maternal deaths in Malawian health facilities, where three factors were found to contribute to the country’s alarming MMR. First, there was a sharp increase in deaths from AIDS in the decade leading up to the millennium. Second, fewer mothers gave birth in health facilities, as the proportion of births attended by a trained health worker actually fell from 55 to 43 per cent between 2000 and 2001. Third, the quality of care in health facilities deteriorated. According to this report, the proportion of deaths associated with deficient health care rose from 31 to 43 per cent between 1989 and 2001.

“To me, it is obvious that maternal mortality can be related to three key notions. Our patients are poor, female and voiceless. We cannot do much about their poverty in the short run or the fact that they’re female, but we can give them a voice. My hope is that this is now about to happen. It’s a political thing in the end; if the patients stand up and demand something, if they have a voice to speak out with, things will change. But it will take a while,” he says.

SEEKING HELP IN TIME | Grace Maliseni (26) and Joanna Jonathan (18) are both expecting to deliver within the next few weeks. As opposed to many of their Malawian sisters, they have travelled to the hospital early in case they experience complications. “It is safer this way,” says Maliseni. Photo: Kjersti Brown

NO PRIVACY – NO DIGNITY
It is rainy season in Lilongwe, and the air is humid. The odour throughout the crowded hospital, as Dr. Meguid guides us through the facilities, is not for the faint-hearted.

“Look at these buildings. They were built in 1937,” he mutters.

“This is the admission room, where the midwives see patients. There’s not much privacy here. Certain intimate questions need to be asked, and of course anyone can listen. We raised some money to build this wall not long ago, so that the counselling and the HIV-testing would be a little more private. The prevalence lately (the percentage of HIV-positive patients) has been at about 18 percent, but it varies.”

“In these fourteen beds we deliver over a thousand babies a month,” Dr. Meguid says, opening the doors to the chaotic labour ward.
Patients are not allowed to bring anyone with them in here, he explains, there’s simply no room.

“The women are all alone, so to speak. Some of them are children themselves, only 12 years old.”

In the hallway outside the operating theatre, a naked woman is curled up on a narrow rolling bed. She’s waiting.

“This woman is either going to be operated or has just been operated. And this is our only theatre. For a place where we deliver so many babies, this is by its very design a human rights violation. If the theatre is occupied and your baby has a problem – well, bad luck. You wait. Babies and mothers die regularly here because there’s only one theatre. You deprive the woman of her child, or you deprive both the child and the woman of their right to life.”

After delivery, patients end up in a small room for a short period of recovery.

“As you can see, there’s no privacy whatsoever here. There will be a patient who’s just lost her baby next to a patient who’s delivered normally next to a patient who’s had a traumatic delivery in one way or another. We are not able to treat them with dignity. Again, 12 000 to 13 000 women a year; you don’t have anything like that in the Northern hemisphere. A building like this is abuse. Providing no privacy is abuse; it’s a violation of their rights. The message to you as a patient is: you are worth nothing. You are nobody.”

KAMUZU COLLEGE OF NURSING:
Only a short drive from Bwaila Hospital we find our way to a room full of bright faces, most of them students. The University of Malawi’s Kamuzu College of Nursing (KCM) is launching the NUFU project Improving access and quality in maternal health care in sub-Saharan Africa, having received funding for the period 2008 to 2012. KCN is the oldest and so far the only training institution for professional nursing and midwifery that has produced graduates in Malawi. Their mission is to deliver quality and cost-effective education to students with the ultimate aim of providing better health care services for the people. Training students to Bachelor’s, Master’s and University Certificate level, KCN’s total number of enrolled students in 2009 is 155. This number has more than doubled over the last few years.

“There are many qualified students who want to do nursing, and the college has capacity for a bigger intake. But there are limitations, such as inadequate accommodation and teaching facilities. Despite the large increase in enrolments over the recent years, the intake infrastructure has remained the same,” says College Principal Dr. Address Malata.

According to her, KNC encourages students to work for government and other health institutions after graduation.

“Issues of deployment lie with the government and other employers to recruit and retain. We only train,” she says.

After a warm welcome by Dr. Malata, who is coordinating the project with Professor Johanne Sundby of the University of Oslo, the students are guided through some of the work ahead. A substantial part of the project consists of examining the quality of maternal health care and the causes of maternal mortality in Malawi and Tanzania. Four PhD-students and one Master’s-student are so far involved, two of whom are doing their field work at Bwaila Hospital. Problems are being addressed from different angles; maternal deaths are being traced back to respective families in the communities, and research on how to improve prevention of mother-to-child transmission of HIV and how to involve men in birth assistance is being done. Staff burnout is another issue that they are looking at.

“All the students involved are committed to trying to break down some of the structural and cultural barriers related to maternal health in the region,” says Professor Sundby, from the International Health Section of the University of Oslo’s Institute of General Practice and Community Medicine. With a background as a gynaecologist, she has worked on reproductive health in a number of African countries since 1993.

“I started my professional career working on involuntary childlessness. Gradually my focus shifted towards traditional taboo issues such as circumcision, abortion and sexually transmitted diseases. My concern regarding maternal mortality was a natural extension of this, as at some point it became painfully clear to me how urgent the matter of improving maternal heath on this continent really is.”

REALISTIC EXPECTATIONS

The challenges and obstacles presented by this task are just as overwhelming as Malawi’s maternal mortality rates are appalling. Sundby is realistic, and her aims in terms of project results are sober.

“If you’re a researcher looking for quick and ground-breaking results, you certainly wouldn’t be working on maternal health in sub-Saharan Africa,” she says.
“However, the project will lead to capacitybuilding by supporting the further education of five young women who in the future will be
contributing their much-needed knowledge and skills in their home country.”
On the Norwegian side, Sundby is collaborating with Informatics Professor Jens Kaasbøll, also of the University of Oslo. The two had been discussing working together for years. Research shows that health information systems in most developing countries are inadequate, and in the case of Malawi, it was obvious that the reward in terms of synergy between the two projects would be big.
Through funding by the Norad’s Programme for Master Studies (NOMA), Professor Kaasbøll is coordinating the development of two integrated Master’s programmes in health and information systems at the University of Malawi (UNIMA). Drawing on his previous experience from a similar project in Mozambique, Kaasbøll, in collaboration with UNIMA senior lecturer Maureen Chirwa, is working towards increasing the university’s academic capacity and educating students at Master’s level in the development and operation of these information systems.

A HEALTH WORKER’S MARATHON

Back at Bwaila Hospital, the current medical staffing situation is bad. The biggest problem is human resources in terms of quantity, but also in terms of quality, according to Dr. Meguid. In addition to him, as the only consultant and on call 24/7, three registrars and six clinical officers currently bear responsibility for the health of expectant mothers and their babies in central Malawi. The recent loss of seven nurses and midwives has made the situation even worse.

“On most nights, there’s only one nurse for more than a hundred people. What people tend to forget, is that a hospital like Bwaila not only abuses the patients, but also the health personnel,” says Dr. Meguid.

Norway is contributing staff and equipment to the hospital, as obstetricians and midwives from the Universities of Oslo and Bergen come here for six months at the time. They have also mobilised a private donor involved in equipment funding. Meguid still describes the level of over-worked and burnt-out staff at Bwaila as close to 100 per cent.

“If you want to survive as a person, as a health worker, it’s a marathon. You have to accept the unacceptable for years. The obstacles seem insurmountable, and it’s the kind of working environment that forces you to constantly keep up the pressure. Many give up and act accordingly, and some show behaviour that’s not at all OK. Some become cynical or emotionally completely gone; soulless. I believe that you can be revived from this state, but we need more people, and we need them now,” he explains.

When asked how he personally copes with the pressure, he laughs.

“I play volleyball! I’m very angry about the situation here; I try to divert this energy into action, like writing articles at night. I’m too angry not to. At the moment I’m too busy to be doing things on a political level, but maybe in the future I can. I hope things will improve over time; development is generally incremental,” he says.

“For me, seeing the patients it what makes it all worthwhile. I believe that you cannot accept things this way. If you do, then you are part of the problem.”

IMPROVEMENTS AHEAD
Although the staffing situation desperately needs urgent attention, there are improvements ahead at Bwaila. If things go according to plan, a brand new maternity hospital will be up and running some time between May and June this year.

Scottish Tom Hunter from the Hunter Foundation visited the hospital a few years back and decided to provide funding for a new central maternity unit at Kamuzu Central Hospital. The new Bwaila is being set up by an Irish NGO called the Rose Project, and will cater for more than 6 000 district-level patients. It will have two operating theatres, and according to Meguid, the focus is on increasing the quality of care in order to do more justice to the patients.

“The best thing about these two new labour wards is that the district and central levels will be identical; all the women will be given the same hospital experience. I feel very happy that we’ve been lucky enough to receive funding; it’s a once in a lifetime achievement. The new Bwaila will allow us to give much better care, it’s a huge improvement,” he says enthusiastically, walking through the building site.

“It’s amazing; a year ago there was nothing here. We’ll have to wait and see, in the end it’s just a building. But a building can also be an expression of respect for human rights. I really hope it will raise the morale of those who work here too,” he says.

The work in progress consists of a nursing station surrounded by twelve delivery rooms. Ten of them are single rooms, meaning that it is physically impossible to place two beds in the same room. Looking out, the patient can only see the nurses, nobody else.

“It’s the only hospital in Africa with this setup, where the facilities can be used by anybody, not just paying patients. It’s fantastic,” says Meguid. Another essential improvement is that the expectant mother now can bring someone along to delivery.

“When we open the new facilities we will encourage women to bring a husband, friend or a family member, and let everyone know that men are welcome. The fathers will come, I’m sure they will, but they also need time to learn this attitude.”

According to Meguid, the future of Bwaila Hospital is now in the hands of the Malawian government.

“Prospects are excellent if, but only if, the government allows hospitals the autonomy to manage their own affairs, especially when it
comes to human resources. As soon as the important people understand that good human resource management is the key to major improvement, things will really get better, in a sustainable way,” he says.