The Truth about Maternity Care in Chad
Four of us went to Chad last November to assess the situation and birthing needs of Chadian women in the l’Hôpital Général de RéférenceNationale (HGRN). I am a nurse and midwife, Angela is a Neonatal Nurse, Helen da Costa is a nurse and a pharmacologist and Ann was our French/English interpreter. Helen was representing IHP (International Helath Partners) in the hope that in the future, they might be able to help Chad source drugs for use countrywide.Helen and
I have visited hospitals in Africa and other parts of the underdeveloped
world before, but Angela and Ann have not; in fact Angela has only been
to Tangier for aday trip. Ann has travelled a lot in Morocco. However,
nothing really prepares one for the horrors of reality staring one in
the face! The maternity Unit at the HGRN is run by midwives who have undergone
some training but only during their general nursing course. We were reliably
told that many of them start work as midwives, never having delivered
a baby before! However, even a nursing background is better than the birthing
aids who deliver babies in the villages and learn from their experiences
and mistakes.
In the hospital,
most of the women have a member of the family with them because, unlike
in the west, there is no food provided for the patients. It is interesting
to see the relatives coming in with huge trays of eggs, which they cook
on primus stoves in the hospital grounds or in the wards! Some of the
relatives will sleep on the floor on blankets under the beds. The babies
are usully left with their mothers but if their mother is too ill to care
for them, they are taken home to the family to a wet nurse. This is a
very common practice in Chad and indeed throughout the third world. The
babies seem to thrive on it, but one does wonder about the risk of HIV
and AIDS!
The wards
have 4 beds in them with partitions between, if they are lucky. There
is no bed linen at all and the patients stay in their every day clothing,
lying on top of a rubber, not so clean, mattress. Some of their relatives
bring in mosquito nets, as Malaria is very common and they do have a lot
of cerebral Malaria, which is life threatening. The midwives do not assist
new mothers with breast feeding or check their lochia, but a doctor will
do a round of all the patients twice daily. The hospital also has gynaecological
patients who have undergone surgery in the same wards as ante and post
natal patients..
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The labour
ward is sadly lacking in equipment. They just have the bare necessities
for delivery. They do not even have an oxygen supply. There is a very
primitive “Resuscitaire” with a suction unit on it with one
suction catheter! The heater does not work and until Angela showed them,
the midwives had never seem a neonatel ambu-bag! We visited one maternity
hospital in another part of N’Djamena, where they were using plastic
bags from the market as gloves to examine the women! They do not monitor
the labouring mums at all. I did not see one B/P., pulse, abdominal palpation
or foetal heart check on any mother during labour. There seems to be no
concern at all if there is any meconium stained liquor either. However,
I do not think that the situation of an “emergency section”
would be very well dealt with. It would take too long to find a doctor
and there is only one theatre trained nurse, who could be scrubbed a gynaecological
list. There are no western qualified anaesthetists in the whole of Chad.
The only Caesarean sections we heard about when we were there, were all
elective. The midwives do not keep an eye on the hydration of the patients
either and considering the temperature in the Labour Ward was in the upper
30’s, I saw a lot of very dehydrated patients. Two of them had infusions
and that was because they were vomiting. They do not check the placenta
after it has been delivered either! The mothers have no pain relief whatsoever
and are really very stoic about the whole thing and hardly make a sound,
and I saw about 15 deliveries. I also saw a manual removal of a placenta
done by a midwife without any analgesia. Even the gynaecological patients
who have had major surgery, only receive Paracetamol, if the family can
afford them! They deliver the women supine into a plastic bedpan. However,
I did see one lady get off the bed and deliver into the bedpan on the
floor...a much better position! The midwives manually stretch the perineum
frequently during the second stage of labour, but I can honestly say that
the normal deliveries are very well done, but in a different way than
we would conduct them here. I did not see one perineal tear or even a
graze. However, the Chadian women do start to have babies when they are
very young and their perineums seem to stretch very easily. The midwives
said that on the odd occasion that a patient has a tear, it is the midwives
who suture them. They are just shown a few times by another midwife and
then allowed to suture. No form of oxytocin is given and instead of putting
the baby straight to the breast, which would help speed up the third stage,
they wrap it in one of the mother’s sarongs and put it on a tiled
shelf without even its head showing! This is to the only way to identify
the babies, by the material in which they are wrapped. It seems to work
well. If they have a lot of blood or vernix on them, they are held under
the cold tap first and not even dried before being wrapped in the cold
waxed non- absorbent cotton sarong. Thus, they get very cold and if one
of them stops breathing nobody notices. C’est la vie en Tchad!
After delivery, the mothers are left on the labour room bed until the completion of the third stage and then they go home or if there is a spare bed, they are allowed to rest for a very short time. The babies have a rubber band put on the umbilicus from a sterile box containing a pair of forceps and a pair of episiotomy scissors which are used to cut the cord.. The cord is them wiped with disinfectant and the baby is bandaged around its middle with a clean cotton bandage. Interestingly enough, I was trying to source some umbilical clamps on the internet for Chad, only to find that many patients in the west prefer rubber bands!
One thing that was strange to me was the lack of medical staff in the labour ward. They do not seem to play a very active part there at all. I saw a breech delivery done with the woman lying supine and two midwives yanked the baby out with tremendous force over her abdomen. The sad result was a dead baby, possibly from a broken neck. I will have that terrible sight on my mind for the rest of my life. The labour ward beds do have stirrups on them so they could have done a traditional breech extraction but I did not feel, as a visitor, that it was my place to interfere. We used to regularly do breech deliveries when I did my midwifery training and we never had a death. One asks “why do they not do a Caesarien section”? Well, the reason is that the women tend to have a large number of babies and also if they have a Caesarian when they go to hospital, it will put them off ever going to hospital again and the next time they will opt to deliver at home.Then there would be a large number of ruptured uteri in Chad.
We saw quite a lot of severe sepsis. There was one women who had had a “back street” abortion because she had a 21 month old child and they could not afford another one. She had severe septicaemia and the family could only afford 2 vials of intravenous antibiotics from the pharmacy. Fortunately, we had provided some IV antibiotics with which she was treated free of charge and happily recovered. The family were so grateful to us and could not understand how the woman had been able to have free treatment. They said that it was unknown in Chad until then. The usual outcome would have been death. There was another woman with septicaemia from bilateral breast absesses which had been incised and drained. She also benefitted from free intrvenous antibiotics. We spoke to women in the streets and they all had friends and relatives who had died in childbirth. They say “when you go into hospital to have a baby, you already have one foot in the grave”. A rather poignant statement I think?
The incidence of pre - eclampsia is very common and is the main contributing factor to the high mortality rate of 1:11. The young age of the primigravidae is one of the most important factors in pre-eclampsia. Some of them are as young as 12 years old when they deliver. We took out some Magnesium Sulphate, which has been a life saver for the Chadian women. Since last November, when we were there, not one woman has died of eclampsia. This will make a huge difference to Chad’s maternal mortality statistics, coupled with the supply of free antibiotics for those who cannot afford to buy them.
The hospital
has an antenatal clinic that some patients attend and surprisingly enough
the midwives keep good records. The patients are offered an HIV test,
but they do not have to have one, so the statistics for HIV in Chad are
completely inaccurate. I would guess that it is as high as many of the
other African countries, but one cannot prove it and prbably never will
be able to do so.
The visit was a very useful experience bacause it made us realise that
we can never bring Chad up to western standards and there is no point
in trying. It would be like trying to run before one can walk. Our mission
must be to save women and babies from dying when possible. I say, when
possible, because there is no point in resuscitating babies who are obviously
“in a bad way” because there is nowhere for them to go post
resuscitation...no neonatologists, no incubators, no neonatal intensive
care and no surgeons to operate on congenital abnormalities, if present.
Due to the fact that many of the people intermarry, the incidence of congenital
abnormalities is high, thus making the neonatal mortality rate high also.
It is really a case of survival of the fittest. There was a baby born
when we were there with severe congenital non-bullous icthyosiform erythroderma
( diagnosed from a photograph by a consultant neonatologist ) as well
as respiratory problems. Apparently survival rate in the west is poor
so it would have had no hope in Chad. We had to just leave it without
trying to resuscitate it and let the mother take it home to die. We would
be doing no favours to anybody if we went in like a bull in a china shop
and resuscitated all the sick neonates. Without continuing care and facilities
for bringing up a handicapped child, I am afraid to say it is a cutting
egde of Life and Death.
By Pippa Zintilis
Click
Here For "Update Report on Maternity Care in Chad
February 2007"