Midwives Make a Difference — Monday, January 27, 2014

The countryside around Adikeala

The countryside around Adikeala

Approximately 85% of births in Ethiopia take place at home, outside a healthcare facility, and without the presence of a skilled birth attendant at delivery.  A normal spontaneous birth without complications can usually be managed by family members, assuming that they do not intervene in well-meaning but meddlesome ways that cause problems themselves (such as maternal infection or neonatal tetanus).  But when problems arise in the absence of immediate skilled attendance, the stage is set for catastrophe.  Obstructed labor—where the baby will not fit through the birth canal—left unattended (often for several days) leads to obstetric fistula, with devastating consequences for the afflicted mother.  Other conditions—such as hemorrhage, uncontrolled hypertension, or intrauterine infection—can also lead to serious illness or death.  Most of these conditions can be diagnosed and treated effectively, avoiding long-term injury or illness, but doing so requires the presence of healthcare personnel who are available, accessible, knowledgeable and well trained, and who have the supplies and equipment they need to do their jobs effectively.

There are not nearly enough obstetricians in Ethiopia to meet the healthcare needs of the female population, and rural areas throughout the country are particularly under-served.  As a matter of simple justice, no pregnant woman should be made to deliver her child without the supportive presence of a skilled delivery attendant who can diagnose and treat basic emergency obstetric conditions, stabilize critically ill patients, and refer them to a higher level of care when needed.  Obstetric fistula can be prevented, for example, if the diagnosis of obstructed labor is made soon after labor becomes obstructed and appropriate treatment or referral is initiated promptly.  It is only when obstructed labor becomes prolonged that the terrible injuries to the mother’s pelvic tissues begin to occur, resulting in a fistula.

The solution to this problem involves training midwives and posting them to rural areas where access to healthcare services is poor.  But simply posting midwives to rural areas is not enough.  Midwives must be placed into a system that enables them to do their work well.  They must be supported—financially, emotionally, and professionally—so that they can be effective clinically and satisfied professionally.  They need colleagues and supervisors with whom they can discuss problematic cases as well as defined pathways for the referral of difficult cases whose management lies beyond their skill-set.

This is the mission of the Hamlin College of Midwives.

Eradication of obstetric fistula will only occur when prolonged obstructed labor is no longer common.  Since obstructed labor is a natural complication of human reproduction, obstructed labor will never be totally eradicated (some babies just will not fit through their mothers’ birth canals!), but the long intervals that often currently exist between the onset of obstruction and appropriate intervention can be reduced to a point where fistulas do not occur.  Indeed, this is what has happened in Europe and the United States, where obstetric fistulas from prolonged obstructed labor are now virtually unheard of.  This will only come to pass when every woman receives appropriate monitoring during labor and prompt intervention if labor becomes obstructed.

Helen next to a life-saving motorcycle ambulance at Adikeala Health Center.

Helen next to a life-saving motorcycle ambulance at Adikeala Health Center.

Joe Kinahan, Vice-President of Hamlin Fistula USA, examines the motorcycle cab with Helen.

Joe Kinahan, Vice-President of Hamlin Fistula USA, examines the motorcycle cab with Helen.

The Hamlin College of Midwives is the premier midwifery training program in Ethiopia.  By itself, it cannot begin to meet the need for midwives that exists throughout the country, but it can serve as a model of how to train highly-skilled clinical practitioners, how to deploy them effectively in the countryside, and how to give them an enabling environment in which to carry out their jobs.

Today we made a visit to the Adikeala Health Center about 40 km outside of Mekelle, where two graduates of the Hamlin College of Midwives are deployed.

The Adikeala Health Center

The Adikeala Health Center

Although Adikeala is only 40 km outside of Mekelle, it takes at least an hour to get there by road, and only the most hardy of travelers would attempt the journey in something other than a four-wheel-drive vehicle.

A bus barreling down the road from Adikeala

A bus barreling down the road from Adikeala

Roadworks near Adikeala

Roadworks near Adikeala

The Hamlin College program is a four year midwifery training program, with heavy emphasis on the acquisition of practical clinical skills and a competency-based evaluation program.  This sets Hamlin apart from most of the midwifery training programs in Ethiopia, which tend to be “text-based” with an emphasis on “book learning” rather than on hands-on management of deliveries and obstetrical complications.

Hamlin midwifery students are recruited from rural areas where the need is great, and are sent back to their communities.  They are given housing and are sent out in pairs so that they have both a colleague to work with and clinical back-up to insure that the case load does not get too great.  Additionally, each midwifery post is equipped with a small motorcycle ambulance for emergency transport and a defined communications and referral link to a center capable of providing advanced emergency obstetric care.  Most of the midwifery centers are located in larger primary health care facilities rather than as “stand alone” units, providing additional clinical backup for the midwives.  The midwifery centers are located within reasonable proximity to the five Hamlin satellite fistula centers scattered throughout Ethiopia in Mekelle, Barhir Dar, Mettu, Harar, and Yergelim, providing an integrated system that can gradually be expanded as more midwives are trained.

Duplex housing for Hamlin midwives in Adikeala

Duplex housing for Hamlin midwives in Adikeala

Cistern for collecting rainwater at the Adikeala Health Center.  This will only last about two months.  Water shortages are a chronic problem in the parched climate of rural Tigray.

Cistern for collecting rainwater at the Adikeala Health Center. This will only last about two months. Water shortages are a chronic problem in the parched climate of rural Tigray.

The Adikeala Health Center has two Hamlin-trained midwives, Beletu and Zufan, who have each been there for around two and a half years.

Midwife Zufan

Midwife Zufan

They are one of the most highly-rated midwifery sites in the Hamlin organization—and they are busy.  In the last six months they have done 247 deliveries themselves and have referred another 26 high-risk patients for more advanced medical care (9.5% referral rate).  The general “rule of thumb” is that 15% of all pregnancies will develop significant complications that require referral so they are close to the expected obstetrical metric. The Adikeala Center serves a 10 km radius and there are roughly 27,000 people within its catchment area.

When we arrived for our visit, there were three women who were immediately post-partum (the average stay for an uncomplicated delivery is only 6 hours!), and one woman was in early labor.

Abrha, in early labor, is comforted by her mother, Azmru, while Zufan watches.

Abrha, in early labor, is comforted by her mother, Azmru, while Zufan watches.

Ethiopian Orthodox religious icons in the delivery room, for the comfort of women in labor.

Ethiopian Orthodox religious icons in the delivery room, for the comfort of women in labor.

After delivery patients receive a home visit, usually within 24 hours, and follow-up at 3 days, 7 days, and 6 weeks at the health center.  World Health Organization guidelines suggest that 4 antenatal visits are adequate, unless problems are uncovered.

Focused program of antenatal care:  Four visits are usually enough for uncomplicated  pregnancies.

Focused program of antenatal care: Four visits are usually enough for uncomplicated pregnancies.

The midwives keep a running record of all pregnant women in their catchment area to keep track of who might develop problems.

Log of currently pregnant women in the Adikeala catchment area.  Surveillance is the key to heading off life-threatening complications.

Log of currently pregnant women in the Adikeala catchment area. Surveillance is the key to heading off life-threatening complications.

They seem happy, well-respected, and are an outstanding example of how to improve maternal health in Ethiopia through thoughtful infrastructure development.

Midwives Zufan and Beleu in conversation with Lewis.

Midwives Zufan and Beleu in conversation with Lewis.

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