Delivering amid mountains of challenges

By Tsitsi Matope

MASERU — It is 8am and 31-year-old Nthabeleng Ramone is one of the mothers already waiting for services at ‘Mabatho Clinic and Maternity Home in Maseru’s high-density suburb of Sea-Point.
Ramone gave birth to a bouncing baby girl here six weeks ago and is back to have her checked while she also consults on family planning and other maternal issues.

“This is my second baby. I am back here because I was happy with the good treatment I received during my pregnancy and when I delivered my daughter. I liked the fact that the labour ward was not congested and, as a result, I received a lot of attention,” Ramone said last Friday.

A few metres from where Ramone was breast-feeding her baby, some pregnant mothers sat eating some juicy peaches which are abundant in Lesotho during this time of the year.

Others, who were obviously waiting for health-services at the clinic, chatted while they awaited their turn.
The facility, established in 2007 by Joalane Khoarai, might not look like your regular clinic, but local residents who spoke to the Lesotho Times, expressed gratitude in having such an essential service at their doorstep.

“In case of emergencies, even at night, we can always call the owner to attend to us. It’s good that she is doing this incredible work; we appreciate the good service she is bringing to our community,” one of the residents, ‘Mateboho Mohapi, said.

The clinic is a simple three-roomed house, which encompasses the consultation and maternity rooms and waiting area. From outside, it might not look much but once indoors, it is easy to see why those who have been attended to here have nothing but praise for Khoarai whose innovation has served them the agony of attending the nearby and crowded local government-run Domiciliary Clinic.

“It is for that reason I decided to provide an alternative service and help contribute towards strengthening primary health service delivery in Maseru,” said Khoarai, one of the few local professional nurse-midwives running their own clinics and providing much-needed maternal healthcare in the country.
Khoarai strongly believes Lesotho needs a strong primary healthcare system to reduce pressure on the referral hospitals, many of which have been struggling to cope for years.

Apart from delivering babies, her clinic also provides other services that include curative, antenatal, postnatal, HIV testing and counselling as well as family planning.

“I saw the need to compliment government’s efforts when I was working in government hospitals between 1983 and 2006.”

Khoarai was at Mokhotlong Hospital (1983 to 1989), Butha-Buthe Hospital (1989 to 1992) and Queen Elizabeth II Hospital (1992 to 2006) where she witnessed some harrowing situations, which eventually convinced her to establish complementary health services within easy reach of communities.

“I witnessed worse situations in the mountains, where pregnant women would walk long distances — only to arrive at the hospital to die because they would have come late or the systems were not supportive or competent enough to save their lives,” said Khoarai.

“I also helplessly watched some mothers and babies gasp for air before they died due to lack of oxygen. I saw some mothers bleed to death because there was no blood. It reached a point where it really affected me.
“Many nights, I could not sleep because I kept seeing the faces of the dead patients who just happened to be sick at the wrong time. My hair prematurely turned grey and I would panic each time I heard the ambulance siren signalling an emergency. It’s a trauma that has become a part of my life.”

Not that at nursing school Khoarai was never taught that, at times, death could not be avoided. But it was the alarming rate at which it occurred that shook her — and all because the health systems would be more ailing than the patients themselves.

“The irony was that when I moved to Queen II Hospital to manage the maternity ward following another struggle to save the lives of mothers in the mountains, I was faced with a situation that really troubled me.”

She explained how Queen II was an accident waiting to happen, with virtually nothing in prime working condition.

“Nothing just seemed to work for any reasonable length of time — from the showers, toilets, and electricity to the department itself which was under-staffed and under-resourced.

“There were lengthy and ineffective procedures to follow if you needed certain work done. For example, for years, pregnant mothers had to endure cold showers because there was something wrong with the maintenance department. And after a series of follow-ups yielded no result, it was only reasonable to grudgingly accept the reality on the ground, but it was really frustrating.”

She explained how difficult it was for the maternity ward to manage the pressure.

“There was just one gynaecologist during my time at Queen II, and eight midwives who were split into two groups. This meant at any given time, there were four midwives working in the ward while the other four were off-duty.

“The four would be responsible of admissions, deliveries, taking care of the abandoned babies, transporting mothers to and from theatre and ensuring the availability of medicines and administering the drugs.

“There was a time when close to 40 clinics in urban and rural Maseru were not delivering babies. We would deliver more than 600 babies per month and out of this figure an average of 40 were delivered through the caesarean section. What this meant was the bulk of deliveries were not complicated and could, therefore, have been handled at clinics.

“The bottom line is, we worked extremely hard and were short-staffed and had no adequate or reliable equipment. We had one machine to resuscitate babies, one oxygen set in a ward of 91 beds.

“If there was no oxygen, then it meant someone who needed it died. Mothers had to bring gloves for the midwife who would help them deliver. Some mothers slept on the floor and they had to bring blankets from home while in some cases, two mothers would share a single bed.

“At the end of the day, tired and battling to remain focused, in most cases we ended up just trying to ensure the mothers delivered safely under the difficult circumstances. The pressure compromised the overall quality of service in a very serious way.”

The environment, she added, was such that it was not a surprise some mothers would be infected with diseases right inside the hospital.

“As the maternity ward manager, it was also my duty to report maternal deaths. It was the most difficult part of my work because how do you explain the death of a pregnant mother who came to the hospital on her own and not showing signs that her life was in any real danger, only to come out in a coffin? Getting pregnant and delivering are natural processes that apply to humans and other species including wild animals.”

She also explained how, in such challenging times, it was difficult to get support from some of her superiors.
“The problem was focus was not on the real issues that made it difficult for us to provide high quality service but on midwives who were expected to perform miracles.”

Khoarai further said the maternity ward then did its best to provide focused pre-birth and post-delivery services.

“Our approach was one of the reasons why in the 1980s and 90s, maternal death was not as high as it is now.”

According to Khoarai, through focused service-provision, midwives then thoroughly examined the mothers to identify, among other factors, the position of the baby and location of the placenta through ultrasound technology.

“We knew the diseases that killed most mothers were pregnancy-induced hypertension, bleeding, infections and obstructed labour. Our services would, therefore, strive to look for any signs of such conditions to make sure they were managed early before and after delivery. This focused service provision deteriorated in the 2000s. Today, most health centres no longer consistently provide such thorough examinations on each visit.”

Khoarai also said while HIV and Aids have presented other challenges to efforts to save mothers, most women die as a result of neglected complications suffered during and after delivering.

“There are a lot of issues that we need to critically look at. For example, are we convinced that having inexperienced midwives running some clinics in some remote areas makes sense? Are we grooming the midwives to become ideal caregivers who understand the importance of infection-control and how to do it starting with the dress code?”

According to Khoarai, although Lesotho’s present maternal health situation is depressing, she is happy the government has made midwifery training a compulsory course in nurses’ training programme.
“What needs to be closely assessed is the effectiveness of the new practical-based nurses training curriculum.”

Khoarai added that the government and various partners should also work towards ensuring maternity wards are well-resourced to improve services, thereby reducing unnecessary deaths.

“My dream to establish a clinic was inspired by my past experience. I saw the need to implement systems that critically responded to the situation on the ground. I wanted to be in control of those systems and make sure I continuously improved them to remain relevant.”

Khorai runs her clinic with one professional nurse and they both deliver an average of 25 babies per month.
“Because I have seen the dangers of late-detection of complications, we have developed an efficient detection system. Mothers found to have conditions that might pose challenges during delivery are immediately referred to other hospitals.”

Khoarai said with support, she would like to further develop her clinic to become a mini-hospital.
“Such a development would call for improved technology, which would enhance the services we provide here. Again, one day I would like to expand services to provide male circumcision services.”

However, Khoarai said support has been hard to come by, but she would not give up.
“It is sad because the maternal health crisis in this country demands we work collectively to ensure services needed the most are provided in all parts of the country.
“Unfortunately, this is not what we are all striving to achieve. We tend to waste time on very trivial matters. The issue is not about how midwives who are passionate about this profession would get rich when they are supported but about how we can all save our nation from possible extinction. Midwives in all districts can help make a difference where there are no government health centres.
“However, most midwives cannot help unless the environment becomes conducive and supportive enough. We need to admit we have a crisis in order for us to effectively improve our strategies and change our attitudes.”

She further explained how, with adequate support and incentives, retired professional midwives can effectively collaborate with traditional birth-attendants, particularly in the hardest-to-reach areas of the country.
“Traditional birth-attendants should not be dismissed just like that; they can also do an excellent job in helping mothers deliver at home and referring difficult cases to relevant healthcare centres early. I have seen what they can do and how they helped us during my time in government.”

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