Sunday, 28 March 2010
Dodging Impediments to Wrestle Maternal Mortality
By Gregory Gondwe
Nyuma Harawa, 35 thought she would never go to a hospital again to deliver when she had her second pregnancy.
In 1995 when she had visited Mzuzu Central Hospital while in labour, nurses insulted her for failing to deliver in time when she had entered the delivery room.
“Don’t waste my time; I have other pregnant women equally in need of my attention, please do not irritate me as if it is me who impregnated you,” shouted a female nursing officer at the time.
After delivering, Nyaharawa as Nyuma is traditionally called, vowed never again to deliver at any hospital facility because the nursing officer who shouted at her was a fellow woman and she could therefore not understand why she insulted her in the way she did.
The experiences exemplified above is one typical case that talks more on the attitude of some health personnel which scares away pregnant women from health facilities. This is but one of such factors that have contributed to the maternal mortality.
Malawi government committed pen to paper to satisfy all the requirements to reach United Nations’ Millennium Development Goals (MDGs).
The MDGs are the world’s time-bound and quantified eight targets for reducing poverty by 2015. Goal number five compels countries to reduce maternal mortality by half.
The Health Ministry in collaboration with the Maternal and Child Health Integrated Program (MCHIP) is implementing a performance and Quality Improvement (PQI) initiative in Reproductive Health (RH) Services as an effort to improve its quality countrywide.
Although Government has gone flat out in an effort to reduce the number of women dying because of child bearing, the country’s efforts have been met with a number of shortfalls.
In order to deal with some of such shortfalls, the United States government through its agency for international development (USAID) is taking a central role in the programme through its assistance to an organisation called JHPIEGO.
Mrs. Tambudzai Rashidi is JHPIEGO’s chief of party and explains that the role her organisation takes to help hospitals achieve this feat was first started when the ministry of health requested her organisation to help them in the area of performance quality improvement to develop the quality of services.
“Back in 2002 we worked with the ministry of health in the area of infection prevention and as you are aware to date 13 hospitals have received recognition for quality improvement in infections prevention,” explained Rashidi.
She further explained that in 2004 the ministry again requested USAID and her organisation’s technical support in the area of reproductive health.
“We believe that it’s not an individual donor who can overcome all the challenges in the health sector especially quality improvement,” she observed.
In order to achieve success collectively therefore she said JHPIEGO work with the hospitals, the directors of the hospitals, management team and a group of health workers who they call quality assurance coaches who are like the facilitators of the whole process.
“My organisation, JHPIEGO, with funding from USAID, was involved in teaching these individuals as well as the managers on the standards that they need to adhere to. Once they get back to the hospital they then teach everybody in the hospital, the health workers up to the level of the cleaners for them to know the standards that they need to use to improve quality of service,” she explained.
This kind of mentoring from the organisation paid dividends in August last year when Mchinji District Hospital won an award for excellence performance in reproductive health services.
On 24 February 2010, Mzuzu Central Hospital scooped the award and Deputy Health Minister Mrs. Theresa Mwale handed over a shield to the hospital to signify the health facility’s excellence performance in reproductive health services.
“It is indeed an honour for me to preside over this special occasion where we have gathered to witness and commend the distinguished work of Mzuzu Central Hospital,” said Mwale “the Hospital is being recognised... for its excellent performance in the implementation of reproductive health standards.”
She said this is one of the strategies put in place by the ministry of health to ensure delivery and access to quality maternal and neonatal health care.
“As we all know that the ministry and its development partners in the health sector designed an Essential Health Package in 2004 to be the core part of the SWAP Program of work, whose purpose is to improve Malawi’s health indicators. One area where Malawi has consistently recorded unacceptable levels of morbidity and mortality is in maternal and neonatal health,” explained the deputy minister.
Currently Malawi’s maternal mortality rate is at 807 per 100,000 live births, while neonatal mortality is at 31 per 1000 live births.
She said these are some of the poor indicators, which the ministry of Health and its partners need to work on especially as the world draw near to the date of 2015 when achievement of millennium development Goals will be measured.
“Reduction of maternal and child mortality will be one aspect which will be used to measure performance of Malawi with regard to health services delivery,” she said.
For Malawi to achieve this, Mrs. Mwale said the ministry of health in collaboration with JHPIEGO/Access program introduced the Reproductive Health Standards as part of the Quality Assurance Program in the country.
“Implementation of these standards is currently in a phased approach to allow for close supervision and monitoring by our team of experts,” she disclosed.
To date four central hospitals, 16 district hospitals and 12 health centres across the country are implementing Performance Quality Improvement in Reproductive Health using standard based management and recognition approach.
Since 2006, when the initiative was started it took 3 years before any hospital satisfied the requirements until Mchinji district hospital qualified for recognition by achieving satisfactory performance in all the 12 areas of practice last year.
The areas that are gauged include antenatal care; labour and delivery; postnatal care; cervical cancer; management of sexually transmitted illnesses as well as support areas of management and client education.
“We are therefore here to award Mzuzu Central Hospital that has attained excellence in all practice areas with an average score of 89 %,” she said, describing the success as no mean achievement.
“As I have been advised by the chairperson of the Quality Assurance Technical Working Group that the criteria for each practice area covers all aspects of care while external assessment for validating level of performance is also rigorous and pays detail to adherence of practitioners to prescribe protocols of carer as well as satisfaction of patients,” she explained.
The deputy minister has hope that Malawi can do it because according to the national mortality, figures, which Malawi started with at the time the MDGs were set and the level of decline recorded so far, Malawi could be on track.
Malawi’s maternal mortality rate was at 1120 per 100,000 live births in 2000, and by 2006 was at 807, showing a decline of 28%.
“If the trend continues, it is projected that by 2015, Malawi’s maternal mortality rate will be below 200 and the country will have achieved MDG 5, as we would have reduced by half the 1990 figures,” she said.
While government through the eyes of deputy health minister hopes to achieve the requirements set by the Millennium Development Goal number 5, the challenges that are rocking health facilities suggest otherwise.
Mzuzu Central Hospital for example, braved a number challenges to become the first facility in Malawi to be recognised for its best practices in Infections Prevention before becoming the second institution in the country to receive the award for achieving excellence in standards based management in Reproductive health.
“We are exceptional because we have done it in the shortest period of time than any other health facility in Malawi. This is a clear demonstration of our support and contribution to government in working towards achieving millennium development goal number 5 which has to reduce maternal mortality ratio,” said the Hospital Director Mrs. Rose Nyirenda.
She said the hospital first shared its vision and mission to all members of staff and this was used as their guide towards improvements in implementing reproductive health standards from a baseline assessment of 50% in January 2009 to 89% on external verification in December 2009.
“The path to attain this achievement has not been easy,” acknowledged Mrs. Nyirenda.
She said although the hospital was constructed in year 2000 it was opened while it still had multiple infrastructural challenges.
“The major challenges have been lack of a proper sewer system and poor electrical wiring among others,” she said.
She said with the limited ORT funded to the health facility, they have managed to repair roof leakages, replaced toilets, created short-term sewer systems in critical areas, and replaced electricity poles.
“We have also managed to replace major diagnostic equipment in the laboratory and X-ray departments,” she said.
Evidence that Mzuzu Central Hospital achieved award of excellence in its performance quality initiative amidst many challenges are abound.
It had to contend with difficulties with internal communication due to failure of the switchboard and wiring system and this was on the back of inadequate spaces for provision of maternal health services, integrated outpatient maternal health services, high-risk antenatal, postnatal care, delivery rooms and kangaroo mother care ward.
Like all other health facilities, it has also not been spared from inadequate human resources especially clinicians and midwives.
“We rely on locum to ensure coverage for maternal services and meet increasing demand for services such as cervical cancer screening,” said the Hospital Director.
As if not all these problems were enough it also suffered inadequate funding for drugs as what it used to get was cut off more than 50% during the past two years and yet drug prices continue to increase.
“Shortages continue at CMS [Central Medical Stores] making us rely on private suppliers for both essential and specialised drugs and pharmaceuticals including procurement of sutures and laboratory reagents,” she said.
For the two hospitals to continue dodging impediments that could make them fail wrestle the seemingly run-away maternal mortality and sustain the excellence performance achieved in reproductive health Mrs. Nyirenda suggested a number of required support from central level in a number of areas.
She said there is need for continued deployment of clinicians and midwives, increasing in the drug budget to ensure continued supply of reproductive health drugs and supplies and increased ORT to accommodate major routine servicing and repair of key laboratory equipment.
The hospital director also said there is need for government to invest in infrastructure.
“We need extra wards for High Risk Antenatal and postnatal and additional infrastructure for integrated outpatients reproductive health services,” she said.
Only if government will indeed fulfil these requirements, on one hand, pregnant patients like Nyuma Harawa will be attracted to deliver at Mzuzu Central Hospital while on the other hand Malawi as a country will indeed achieve Millennium Goal Number 5 by 2015, as it would have reduced maternal deaths.