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Liberia: fighting controversy to reduce maternal deaths

16 Sep 2015

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Midwives Naomi and Hannah have been trained in emergency obstetric care and now perform C-sections at Dunbar hospital. Credit: OCHA/Truphosa Anjichi-Kodumbe.
 
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The Ebola Virus Disease outbreak in Liberia killed 184 health workers, leading to a spike in maternal mortality rates in a country which already had one of the world’s highest rates.

The Ebola Virus Disease outbreak in Liberia killed 184 health workers, leading to a spike in maternal mortality rates in a country which already had one of the world’s highest rates. The Government and health partners are piloting a new training approach to try to boost maternal health capacity but not all are in favour.

A glance at the morbidity and mortality caused by the recent Ebola outbreak illuminates the challenges facing the health system in Liberia. A reported 4,806 Liberians died during the Ebola crisis: 45 per cent of the 10,666 people in Liberia who contracted the disease, according to the World Health Organization.

According to a recently-published World Bank report, the loss of health-care workers to Ebola led to a spike in maternal mortality rates, with the Government recording an increase of 111 percent in May 2015, compared to 2013. Liberia’s maternal mortality rate was already extremely high in 2013, with 1,072 deaths per 100,000 live births, according to the 2013 Liberia Demographic and Health Survey (LDHS). In other words, Liberian women have a one in ten chance of dying in child birth compared to one in 8,000 on average, in developed nations.

The World Bank calls for significant investments in rebuilding the health care system, prioritizing training and recruitment of health workers during the recovery phase. The latest statistics from the Ministry of Health indicate that there are just 117 physicians to cater to the needs of 4.2 million Liberians country-wide (as per the most recent statistics).

The Government and its partners continue to try to address the challenges in the health sector. Dr. Obed Dolo, resident doctor at Charles Burgess Dunbar Maternity Hospital in Bong County has championed the cause for “task shifting," in line with the World Health Organization recommendations launched in 2012, which stipulate that access to care may be improved by training and enabling ‘mid-level’ and ‘lay’ health workers to perform specific interventions otherwise provided only by specialists.

This approach is being tested in a pilot project to train midwives to undertake obstetric procedures at CB Dunbar Hospital. Midwives are trained to undertake Caesarean sections, bridge and vacuum deliveries and to treat vaginal lacerations. The project reflects a collaboration between the Ministry of Health, WHO, Maternal Child Advocacy International and the Liberia Medical and Dental Council.

Midwives Naomi and Hannah are the first two nurses to complete the course, each undertaking 18 months of theory training followed by a 12-month internship at the hospital. In the first three months of 2015, they had collectively performed 386 major procedures, including 236 Caesarean sections and successful resuscitation of 72 babies. There were no maternal deaths among cases independently managed by them, reported Dr. Dolo.

On the day that OCHA visited the hospital, Naomi and the one doctor on duty had conducted five normal deliveries and three Caesarian sections by midday. Two other emergency Caesarian patients were being prepared for theatre. The working conditions at Dunbar Hospital mirror those of the rest of the country: doctors and health-care staff are compelled to work back-breaking shifts with few breaks due to the perpetually high demand. Doctors and midwives work for over 60 hours before taking a break.

“We often rest on these beds when the situation allows; otherwise we are busy throughout,’’ said Hannah.

Despite the critical need to boost hospitals’ obstetrics capacity, the Liberia Medical Dental Council has criticised the task-shifting approach over concerns that the 2.5 year-training is not sufficient to address complicated cases and will lead to accidents. Surgeons in Liberia undergo an eight-year training.

As a result, neither Naomi nor Hannah have been issued a certification linked with the training that would enable them to be paid. Naomi, a certified midwife, receives a Ministry of Health salary but Hannah has relied on voluntary contributions from the hospital for over five years. These delays mark a huge setback to the training scheme, said Dr. Dolo. It is difficult enough, he said, to get qualified health workers to agree to work in rural areas where there are serious needs.

“We request the Government to recognise these efforts in order to help save more lives,” he told OCHA. While the Government and health partners continue the dialogue, Naomi and Hannah continue to deliver babies, pay or no pay.