Sunday, March 30, 2014

Maternal health beyond the hospital walls, a perspective from Senegal

Before going to Senegal I had looked up all of the health statistics in preparation for my work.  Maternal mortality is 370/100,000 compared to 20/100,000 live births in the United States.  For Senegal, this is quite an improvement from nearly double that rate in 1990.  Yet, there is still room for improvement and as an enthusiastic, young global health professional, I am trying to figure out my role in the effort.

The natural course would be to work on what I know – training physicians.  Surely there is a need to train more providers and improve the quality of that training, right? In Senegal, the ratio of physicians to population is 1:10,000 (versus 24:10,000) and although there has been an OB/GYN residency training program since 1968 there is still a lack of skilled surgical providers.  Yet in the hospital where I work on the outskirts of the capital, there are 6 part-time OB/GYNs who are all highly skilled and patients receive excellent care.  

We have access to reliable anesthesia, back-up surgeons, pharmacies stocked full of medications, a fairly consistent blood bank, and tertiary care hospitals to receive patients who require ICU level care.  Even more basic than this, but perhaps even more important, there is access to running water, electricity, paved roads, frequent taxis and even the occasional ambulance. These amenities are the norm for this hospital, but consider a rural district hospital a few hundred kilometers outside of the city.  If an OB/GYN is there, they are probably working alone.  They have little back-up.  They may not have anesthesia.  If they want blood, a family member must donate it for fresh whole transfusion.  Hospitals don’t stock medications and though pharmacies may have some of them, patients have to find the money to pay for them.  The referral hospitals are hundreds of kilometers away, and the journey to them is on deteriorating, dangerous roads in whatever vehicles can be found.  If there is electricity, a back-up generator is normally required to accommodate the frequent energy outages and any clean water, let alone running water is a luxury.  It is hard to understand how a physician can work effectively in such settings, let alone live there.

Given all of this as background, perhaps I was fortunate that during my rotation, my team has only lost one patient.  She had a normal delivery at a small community center that was complicated by a retained placenta.  The patient began to hemorrhage and was transferred to our hospital.  On arrival, her hemorrhage spiraled out of control and she showed signs of rapid decompensation.  She was taken to the operating room, her placenta was removed and a transfusion started, but unfortunately it was too late. 

Worldwide, 25% of maternal deaths are attributed to obstetric hemorrhage, making hemorrhage the leading cause of death for women in pregnancy.  Globally, we have seen declines in maternal mortality ratios and programs aimed at improving maternal mortality have taken on some great challenges – training skilled birth attendants, getting clean delivery kits into communities, mobilizing communities to promote prenatal care and delivery in healthcare facilities.  The truth about obstetric hemorrhage, however, and what makes it perhaps the greatest challenge, is that it is unpredictable.  There are few consistent risk factors for hemorrhage and most women who die from obstetric hemorrhage have no known risk factors.  When hemorrhage occurs, women need rapid resuscitation and capable providers with the capacity to intervene surgically.  Our patient had no risk factors, and at the first sign of danger, she needed a bloodbank and skilled, equipped providers at the facility where she delivered - or equally as good, a road and immediate access to an ambulance to get her to somewhere that did. 

While there is still a small piece of global health that I am trained to impact, global health is about so much more than training clinicians.  It is about socioeconomic development, distributive justice, infrastructure and access.  Perhaps it is time for us to take on the more complex systems that affect the health of the populations we seek to improve; to make friends in other areas of development so that governments and societies can create a coordinated approach to improving health.

Rebecca Luckett MD MPH

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