Maternal mortality is a major problem and a cause of great concern: some 300,000 women die every year from complications related to pregnancy, childbirth or the postpartum period, and nearly all (98%) of these preventable deaths occur in Africa. A related problem is that of neonatal and infant mortality: each year more than seven million children under five years of age die from preventable causes, many (40%) within the first 28 days of life. Neonatal death is closely linked to pregnancy and the practices employed during and after childbirth.
In 2012, I travelled across Ethiopia with some colleagues from that country. From Addis Ababa, we set off in an off-road vehicle for Afar, a region with one of the world’s highest maternal death rates (790 per 100,000 live births). My task was to assess the results achieved following the creation of 60 new midwife positions filled by women who had received three years of specialised training through a project implemented by the África Viva foundation.
After reaching the town of Awash, we turned onto a dirt road that led out into the middle of nowhere across a natural park area devoid of the abundant vegetation seen elsewhere. Most of the Afar people are nomadic shepherds. After several hours of dust and dirt, we finally reached a small village. There we were met by one of the local mothers involved in our healthcare training project. She told us that a woman in the village had just given birth. We stopped by the new mother’s house and saw that she and the baby were both doing well, fortunately. The woman had been assisted during the delivery by a traditional birth attendant, who agreed to talk to us. Since traditional birth attendants have no formal training, it is difficult to assess what sort of knowledge they have. Their skills are handed down from one generation to the next, and they are often reluctant to reveal everything about their practices. This birth attendant was cooperative. She showed us the materials she used, how she cleaned them after each use, and how she tied off the umbilical cord. All fine as far as it goes—but what happens when labour takes an unexpected turn? What happens if a woman haemorrhages or has placenta praevia?
In Afar, 90% of women are assisted by traditional birth attendants. Could we improve practice by attracting these attendants into the health system?
We continued on our journey. After driving for another few hours, we reached a small health centre staffed by midwives who had recently completed their training through our project. They were busy attending a woman in labour. I went inside and saw that things were not going well. Labour had stalled and the baby was stuck in the birth canal. The midwife did her best to mobilise the foetus with her hands. There was no monitor and no ultrasound device. The midwife repeatedly checked the foetal heartbeat with a stethoscope. The woman giving birth, who was very young, screamed whenever the contractions intensified. The midwife looked at me and said she was going to use forceps. No anaesthetic of any sort was available.I asked if it was possible to transfer the woman—who probably needed a caesarean section—but there was no ambulance. I offered our vehicle. However, the nearest hospital was 50 km away down a terrible road so the idea was crazy and the midwives told me they almost never took patients there. A patient who needed to go to the hospital had to pay for transport. As getting a car was difficult and expensive, they sometimes went by cart or donkey. If we want to improve health, shouldn’t we also be investing in transport and infrastructure?
Noticing that the foetal heartbeat was even weaker than before, I exclaimed: “We must do a caesarean somehow!”
“But I have no surgical training,” replied the midwife.
“Where’s your surgical technologist?”
“We don’t have one here.”
I am a paediatrician, not a gynaecologist, but I did what I could to help the midwife manoeuvre the forceps and apply pressure to the woman’s lower abdomen. Finally—I’m still not sure exactly how—the baby crowned and was born. The mother had bled heavily, so we offered our own blood for a transfusion. The newborn needed stimulation and oxygen—this time, fortunately, both things were available. The midwife, of course, is a key piece of the puzzle, but the rest of the pieces are also necessary. Without them, it will not be possible to reduce maternal and neonatal mortality. This journey will be far from easy.
Victoria Fumadó, Technical Director of the foundation África Viva , is a researcher affiliated with ISGlobal’s Maternal, Infant and Reproductive Health Initiative . She is also the head of the Infectious and Imported Diseases Unit at the Paediatric Department of Hospital Universitari Sant Joan de Déu .