17 October 2011

Zambia: Challenges of Maternal Health Care

DESPITE the numerous efforts being made by the Government and its cooperating partners, access to quality maternal and newborns health care has continued to remain a major challenge for most Sub-Sahara African countries.

In Zambia alone, it is estimated that approximately eight women die each day due to pregnancy and childbirth complications. Whilst service delivery is constrained by shortages of trained personnel, essential equipment and drugs, and poorly maintained health facilities, there are also significant physical, financial and social barriers which prevent women from accessing essential maternal health care.

Having realised this, a local Non-Governmental Organisation Mobilising Access to Maternal health services in Zambia (MAMaZ) funded by the United Kingdom's Department For International Development (DFID), has stepped up measures to reduce the barriers preventing women from accessing Maternal and New Born-Care (MNC) services.

MAMaZ is supporting district health teams to rest effective ways to create demand, reduce barriers to access and improve referral to maternal health services along the household to hospital continuum of care. MAMaZ country director Abdul Badru explained that the programme complements the supply-side of strengthening of health system, which includes facilities in programme intervention areas with appropriate training of facility staff.

Implemented as an integrated operations research initiative, the NGO is collecting and compiling robust evidence on what works with a view to replicating successful approaches in other parts of Zambia. There are various reasons that are given by different sections of society on the lack of access to proper maternal and newborn care (MNC) at health facilities. Among the various reasons that communities and mothers give for not accessing maternal health care, are some which could be interesting to analyse.

For example, who would have ever imagined that the much talked about human-animal conflict can be among the major contributors to the failure by women to access MNC? In a remote district of Chama in the eastern part of Zambia, this is one of the major barriers why many women have not been attended to by skilled attendants at health facilities.

Norah Chirwa, a mother of five, explains that she has had all her deliveries effectively handled by traditional birth attendants (TBA's), not because she is not aware of the importance of delivering from a health centre. "I am very aware of the dangers of home deliveries. But for me, I live over 30km from the nearest health post. My husband and I are both peasant farmers, and can hardly make ends meet from one month to another.

One of the major reasons for my option for home deliveries is because it is cheaper for me. Labour signs for all my five children begin in the night. This made it very difficult to source for any form of transportation. Chama district is well known to be infested with wild animals such as lions. It is a great risk for both the pregnant woman and anyone accompanying her to go out in the night to look for transport." This coupled with the distance and costs involved, as well as social concerns on who will look after the other children when they are away, the costs of feeding the mother while she is at the health facility, and many others, account for the reasons why many rural women like Mrs Chirwa, would weigh the options against the costs, and opt for home deliveries. There are five core elements in MAMaZ's community level activities.

Community mobilisation: a participatory community mobilisation approach is being used to create demand for emergency and routine maternal and newborn health services, and promote effective home based care. This approach gives priority to effective engagement with the whole community gaining awareness of core maternal and newborn health (MNH) issues, and gathering community wide social approval for behaviour change. The approach works with builds on existing mobilization efforts within intervention sites, including Safe Motherhood Action Groups (SMAGS). Establishment of Community Systems: communities are being supported to set up systems to address the preventing MNH utilization and effective home based care.

These include communal savings schemes, community based emergency transport schemes using bicycle ambulances and oxen and carts, establishment of core groups of mother's helpers who know the maternal and new born danger signs and child health minding scheme which will help free up women's time to be able to access MNH services. Maternal health in Zambia: The Context; Ensuring the health survival of mothers and their newborns is a significant challenge in Zambia, which has maternal mortality ratio of 591 per 100,000 live births and neonatal mortality at 37 per 1,000 births.

Delivery by a skilled attendant is still uncommon and uptake of antenatal care and post natal care is low. Poor road infrastructure, challenging terrain and limited transport options are major constraints to service utilisation and result in delayed transfer of maternal and newborn emergencies. Limited knowledge of maternal and newborn danger signs and concerns about the high cost of transportation and out of pocket expenditure on health, further compound the delays. Health staff with life saving skills will use the ambulances to reach local communities quickly, and also transfer women with complications from the health facility to an agreed meeting point with the district ambulance.

Community Monitoring System: this system generates data on the activities and changes that are underway. It provides information on the performance and utilisation of community emergency response systems, as well as providing useful data for MAMaZ, this also helps to build the community's capacity to document and reflect on the changes that they have brought about through their own effects. Mentoring and Couching Support system: this ensures that communities in the intervention sites receive the assistance they need to move from increased awareness to action.

The support provided is intensive initially, and becoming lighter over time. The mentoring and couching team comprises MAMaZ technical advisors, programme staff, and members of the district health medital team (DHMT). Poverty and illiteracy are also among the major barriers to women accessing MNC. Various studies carried out in Zambia and the SADC region indicate that the more educated a woman is, the more likely she is to ensure that her delivery is attended to by a skilled attendant. However, studies have also indicated that even the education levels of male partners or spouses of women is another contributing factor to women to access the much needed skilled MNC services.

The lack of reliable transport, coupled with transportation costs involved in transferring women to health facilities, especially in rural areas, accounts for about 42 per cent of home deliveries.

The distances between the communities and the nearest health centres account for about 12 per cent of reasons why many rural women still opt to deliver at home.

There is also an information gap among both pregnant women and other community members on the levels of knowledge of pregnancy danger signs to look out for. About 48 per cent of women especially in rural areas are still not well informed on the danger signs of pregnancy to look out for. However, MAMaZ through its community intervention programmes has embarked on training of Safe Motherhood Action Groups (SMAGs), on among other things, the eight danger signs of pregnancy and the importance of evacuating women with such signs to health facilities without any delays.

These danger signs include swollen hands, legs and face, headaches with fever, prolonged labour lasting for more than 12 hours, delayed expulsion of placenta (more than 30 minutes after delivery), severe bleeding, feet or umbilical cord coming out first before the head of baby, severe abdominal pain and fitting.

Along with the knowledge of these eight danger signs, MAMaZ has gone a step further in training SMAGs and communities on what they term the five pregnancy plans as follows; everyone must know the eight danger signs, all women with any of these danger signs must be rushed to a health centre. Families must get involved in preparation of baby delivery requirements, the preparation of transport in advance and source money, food for the pregnant woman and her children.

The importance of antenatal care (ANC) cannot be overemphasised in attaining remarkable reduction in the maternal mortality rate in Zambia. Studies have revealed that more than 50 per cent of pregnant women and some spouses get the required knowledge from ANC services, health talks and community support groups such as SMAGs. MAMaZ does not only contribute directly to the improvement of knowledge on obstetric care and danger signs, but they also provide effective transport systems to help cut down on the distances covered by pregnant women to access MNC services.

This is done purely to encourage as many women as possible to deliver from health facilities where they can be attended to by skilled personnel. MAMaZ, community engagement advisor Miniratu Soyoola explained that MAMaZ works closely with DHMTs to get a better understanding of the challenges faced by communities. Women make significant efforts to ANC visits, they start as early as 3-4 months into their pregnancy, but the trend tends to drop as many of them fail to complete ANC due to various reasons. Some of these reasons include husbands of these women not wanting to accompany their wives to ANC because of fear of the HIV tests.

The women fear the stigma of rejection and possible divorce by their spouses. The fear of lack of bed space at the health facilities also contributes to home deliveries. Confusion on the expected date of delivery (EDD), and the inability to afford baby items and the presence of TBA's, are also top on factors resulting in women not accessing MNC services.

There are also instances where some male spouses are against having their wives deliveries being attended to by male midwives. For example, Chama district is only meeting 22 per cent of women with maternal complications being attended to by skilled health personnel.

The downside of these low numbers of pregnant women being attended to by skilled health personnel is that about 5-15 per cent of pregnant women will require emergency cesarean section delivery, and if these women are not able to access the health centres, chances are more than likely that they will die of maternal complications.

For this reason, it is imperative that efforts such as MAMaZ, CARMMA, and other initiatives aimed at addressing challenges in the administration of maternal health care, are scaled out for the greater benefit of millions of mothers across the country. By so doing, Africa's theme of 'No Woman Should Die while Giving Life,' could be taken a step further and localised in the Zambian context to read 'No Woman Will Die While Giving Life.'

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