No Opportunity to Die

SodziSodziTettey.jpgSodzi Sodzi-Tettey, BSc MBChB, MPH, is the IHI Director of Project Fives Alive! — a partnership between the Institute for Healthcare Improvement and the National Catholic Health Service in Ghana that seeks to reduce morbidity and mortality in children under five.


Below is a May 2012 report from Dr. Sodzi-Tettey, describing the achievements at one subdistrict health post.




“Because of our proactiveness over the past three years, the women do not have an opportunity to die!”


A skilled, assertive, and passionate young community health nurse has over three years declared, deployed, and secured a zero tolerance policy for maternal and neonatal mortality at a subdistrict health post in Ghana’s Central region.


With this achievement, young Esther Eku has challenged, if not debunked, many of the commonly held assumptions and thinking underlying our understanding of some of the key drivers of maternal and child mortality as Ghana works towards achieving ambitious maternal and child health related Millennium Development Goals 5 and 4, respectively.


What are some of these assumptions?


According to the 2008 Demographic and Health survey, there is disharmony between high antenatal coverage rates and skilled delivery. In other words, although most pregnant women attend antenatal clinics while pregnant, there is a potential 36 percent gap in the proportion that actually deliver within facilities under the supervision of skilled professionals. The theory has thus far been that the women are either delivering at home or under the care of traditional birth attendants (TBAs).


When we explore the above with Esther, she is emphatic; “In my community, no one delivers at home!” She knows because she conducts regular home visits, remains in constant touch with all TBAs in her community, and is increasingly seeing and rewarding trained TBAs accompanying labouring women to her community health planning and services (CHPS) compound. The only rare home delivery is one that occurs while the woman is on the way to the facility. Esther’s Tarkwa CHPS compound has thus done a fantastic job of bridging the gap between antenatal attendance and skilled delivery through active community engagement.


Great is the temptation at this point to attribute her success to prompt and easy referrals when presented with cases beyond her capacity, given her status as a primary referral point. Beyond CHPS, cases may be moved up to a health center, which would invariably have a trained midwife at post. Esther’s accomplishments are the more astonishing because, though not a midwife, she has acquired enough delivery skills both in school and at work to manage that critical care gap between active labour and referral to the next level of care.


Do you conduct deliveries here?


“We only do emergency deliveries,” which she defines as deliveries she conducts only when the women come in fully dilated, having laboured at home and appearing at the facility at the point of delivery. Our mental agitation commences when she reveals that out of the total number of women who arrived in labour, she conducted on the average between 30 to 60 percent of all deliveries by herself with sometimes only 40 percent being moved along to the next level.


We are dazed!


If you are conducting almost 70 percent of deliveries, how come no mortality has been recorded? How come no baby has died given that almost 40 percent of the burden of child mortality is in the neonatal group or within the first month of life, out of which 75 percent die within the first week of life? If you are actually delivering women who come in very late, then it would appear that you, a nonmidwife, are selecting perhaps the most critical cases! So tell me Esther, what really are you doing differently, we probed?


She talked about intense and focused antenatal care, including preparing pregnant women for the possibility of referral during labour, about her limited but present “midwifery” skills, about ensuring that a health extension worker accompanied a labouring woman to the next level, and she talked about the use of simple equipment like “bontoa” to suction fluids from a freshly delivered baby. She demonstrated clear understanding about which cases to handle and which to refer promptly.


Her record of about eight deliveries per month
with a 100 percent success rate
was both astonishing and impressive.

Even so, her record of about eight deliveries per month with a 100 percent success rate was both astonishing and impressive. This led to more probing questions. We know that neonatal asphyxia, prematurity, and neonatal sepsis are the three major causes of neonatal mortality, accounting for 80 percent of deaths. Of these three, I would think that prematurity remains out of your control. Asphyxia may reflect the labour management processes, while sepsis may be attributable to antenatal causes, the circumstances of the labour or to post natal, possibly community-related causes. What explains the fact that in some three years, none of your babies has been born asphyxiated, premature, or developed sepsis within the first week of life?


We are the more mystified by the impressive record on birth asphyxia. Health professionals have always argued for the use of a labour monitoring tool called the partograph. This tool, if used properly at the early onset of labour, can give extremely useful information — whether the labour is progressing normally, how effective contractions are, any signs of fetal distress leading invariably to whatever interventions may be necessary. With the women coming in virtually at the point where the baby’s head is in the vagina, Esther and her team simply do not have a chance to put the labouring woman on a partograph. This notwithstanding, her zero percent record on neonatal mortality requires that we pause, reflect, and perhaps raise some heretical questions.


Is the emphasis on the use of the partograph that critical to reducing neonatal and maternal mortality? I ask this bearing in mind the point made by some midwives in critically understaffed subdistrict and district facilities that, bearing in mind their patient loads and the time required to monitor any particular patient on a partograph, it is a challenge to use the tool effectively. If Esther’s good results prove to be generalizable, could a case be made for, at worst, abolishing the partograph altogether or, at best, for modifying it for a simpler, more user-friendly version that is adapted for use in severely resource-constrained settings?


Esther has all but smashed the theory that health workers at the community and subdistrict levels are delaying patients or “sitting on the cases.” In almost every subdistrict that we have visited, it is very obvious that, be they community health nurses or midwives or medical assistants, they are very clear in their minds when and where to refer when certain types of cases come. Typically, we have also argued that the workload at say the district hospital is excessive, compounded by excessive delays in reporting. The anecdotal evidence seems to suggest that this may not be entirely true. In one district, for example, a simple calculation of the mean deliveries per midwife per month showed comparable performance at the subdistrict health center and the district hospital levels. It is also doubtful whether the case can be made that the cases going to hospitals from communities are significantly different from those that go to the lower levels [of care]. Hopefully, these affirmatively disruptive reflections will engender creative rethinking around actual bottlenecks and lead to possible solutions.


At this point, Esther and I are watching each other like hawks at war over a chicken, with me prancing agitatedly in search of her secrets — a reflection of Ghana’s determination to keep the mothers and children alive! Finally, able to bear the relentless probing no more, Esther Eku makes a profound and absolutely powerful statement that completely blows me away.


“Doctor, because of our proactiveness over the past three years, the women do not have an opportunity to die!” I am totally inspired … and dumbfounded! What a powerful thing to say by the committed and young aspiring midwife!

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