By Tsitsi Matope
MASERU- The Independent Midwives Association of Lesotho (IMAL) has expressed concern that women continue to die during pregnancy and soon after delivery.
Lesotho has one of the highest maternal mortality rates in Africa at 1 155 deaths out of 100 000 live births. Although the government continues to introduce new strategies to combat maternal deaths, the implementation of such programmes has not been easy in most hard-to-reach areas.
However, with enough support, new innovations and ideas by organisations such as IMAL might just help improve maternal health.
The Lesotho Times’ Tsitsi Matope (LT) this week met with the IMAL president, Francisca ‘Mapitso Matsoha (FM)—who is also a regional board member of the Confederation of African Midwives Associations (CONAMA) and a retired midwife—to discuss the future of maternal health in Lesotho.
LT: Lesotho is among the countries recording a high number of maternal mortality in Africa. What new innovations can be introduced to ensure safe delivery and the survival of mothers?
FM: We need to do a lot and this is a matter that all stakeholders should be concerned about. Firstly, if you look at the landscape of our country, you will see that we have challenges when it comes to ensuring the development of infrastructure in all areas known to be hard-to-reach. This lack of development extends to health centres. What we need to do to save the lives of mothers is to invest significantly in models that have worked in other countries with similar topography. This includes utilising retired midwives, introducing induction-courses for the midwives that have just graduated and in-service training for those who have been in the field for some time. This training should mainly focus on how to prevent conditions that are killing mothers and how best to care for women during pregnancy, during and after delivery.
LT: Which of these models can Lesotho replicate?
FM: New Zealand’s Out of Hospital Midwife-led Units is one such model. What it basically does is to utilise midwives who retired or are no longer actively employed to provide services within their communities. What we can do in Lesotho is to take inventory of such midwives in our various districts and provide all the support they need to operationalise established units in areas where there is great need.
LT: Can they also provide home-delivery services?
FM: Yes; they can help mothers deliver babies at home. There is nothing wrong with that for as long as the delivery is under the care of a skilled midwife.
LT: What role can traditional midwives play? Can they help to deliver babies in the absence of a professional midwife?
FM: They can only be advocates to encourage mothers to deliver under safe health facilities supervised by professional midwives. They have limited capacity when it comes to helping mothers deliver safely.
LT: But this is a reality in the hard-to-reach areas; traditional midwives who include elderly women, are helping mothers to safely deliver babies…
FM: Under normal circumstances, this should not be allowed to happen. Health-centres and mini-units, if I may say, should be established in those hard-to-reach areas to provide the services. We should be more serious and move away from allowing structures that can endanger the lives of mothers.
LT: Mothers are not only dying while giving birth at home under the care of traditional midwives, they are also dying in big numbers in hospitals and clinics manned by professional midwives and doctors. From your experience as a midwife, why are we in such a situation?
FM: The situation was not as bad during my time as a midwife as it is now and the biggest question is why now? I think the most important thing would be looking at our facilities to see if they are providing that safe environment that can promote the safe delivery of babies. Establishing conducive environments entails having everything which is needed to ensure the safety of mothers, such as equipment, drugs, including Anti-Retroviral treatment, blood, enough midwives and other support staff. On the other hand, we should not forget that having midwives who have low self-esteem and are not motivated can also contribute to the shocking statistics we are now seeing. To my knowledge, there are a number of challenges regarding the accomplishment of fully-fledged working systems at most of our health centres throughout the country. The loss of midwives to other countries that offer better incentives and high incidences of HIV and AIDS have also transformed our health sector. But we should not always be quick to blame AIDS and brain-drain; we should find ways to effectively deal with these challenges.
LT: So during your time (in the 1980s and 90s), did you have everything you needed to ensure safe-deliveries?
FM: Not really, there were challenges too. I have worked under difficult circumstances with scarce resources but then, I was committed and cared about the dangers of turning a blind eye to a mother in labour. Most midwives were committed during our time. I can safely say what drove most of us was the passion for the job. Times have changed. Not all people joining the profession now are doing it for the love of the job but in some cases because it is available. It is a dangerous and chilling situation to imagine having such midwives in our health centres.
LT: So this dire situation is due to a combination of factors?
FM: Yes; in addition to lack of commitment, it can also be a case of lack of motivation in the form of trainings, retreats and encouragement and support to the midwives to attend refresher courses and conferences where they can learn how other countries are coping. This might not sound important to other people but the truth is that knowledge has a shelf-life; even if one has a PhD he or she needs to learn the new things happening.
But of-course, there are many factors affecting service-delivery and if we add these up, we will understand why, in some instances, mothers are dying in the health facilities where they are supposed to be safe. We know that emergencies can happen but we should enhance our systems and do all we can to prevent the death of both mother and child.
LT: The issue of complications and then referring mothers to hospitals is a common practice at most clinics. Is it an issue of limited skills, resources or both?
FM: Firstly, midwives must take charge of their profession. We are seeing some general practitioners now commercialising mothers because midwives are not taking charge. It does not make sense to refer a mother in labour and then when she gets to the hospital, she delivers normally. Unless a midwife spots something threatening to hamper normal delivery, they should take charge. Giving birth is like driving. A driver can suddenly stop after noticing there is a detour. A baby too can also encounter some problems while on its way. A good midwife should be able to tell whether it is necessary to refer mothers to the hospital. Unfortunately, the tendency at some clinics is to unnecessarily refer mothers and this overwhelms the hospitals.
LT: But what can mothers do since when one is in labour, it is difficult to know what choices to make or how serious your condition is? They absolutely rely on the midwives and the doctors.
FM: It is important to empower the women to know their reproductive rights and understand they have the freedom of choice. They are allowed to ask if they don’t understand something. Child-delivery is something very personal and therefore, all mothers should have interest to know the process from pregnancy, delivery and after delivery. It is their right to become involved and ask questions.
LT: Do you think mothers in remote areas have such freedoms, where many are lucky to even access the services and be cared for by trained midwives?
FM: It is a big challenge for the bulk of mothers living in the rural areas. What we need is for all stakeholders to join hands and ensure easy access to services. That should be our big start because when the services are there, it is easy to educate the mothers about their rights. The second step would be reaching out to all women of child-bearing age and also educate them about these rights. For example, it is their right to give birth in the presence of one member of the family such as a sister, aunt or husband. Relatives are allowed to ask the name of the midwife caring for the mother in case something happens and they have to follow-up.
LT: So what makes an ideal midwife?
FM: A midwife is a person who successfully completed a midwifery education programme that is duly recognised in the country where it is located. The programme should be based on the International Confederation of Midwives’ Essential Competencies for Basic Midwifery Practice and the Framework of the ICM Global Standards for Midwifery Education.
LT: What are the responsibilities?
FM: The midwife is a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the post-delivery period, to conduct births at their responsibility and to provide care for the newborn. This care includes preventative measures, promotion of normal birth, early-detection of complications in both the mother and baby, accessing of medical care and ensuring other appropriate assistance which includes carrying out emergency measures.
LT: Can a midwife work alone without the supervision of a gynaecologist or obstetrician?
FM: Yes, but sadly, there is a notion that they cannot. Some midwives also feel intimidated by some professionals and I don’t understand why in some cases, midwives are not confident that they are experts at delivering babies. A gynaecologist can treat infections in pregnant mothers while an obstetrician is the one who deals with midwifery issues. In most cases, the gynaecologist is also an obstetrician.
LT: Tell us what are the major issues emerging from your association?
FM: Well, we have received a lot of support from the International Confederation of Midwives (ICM) in terms of helping us attend various international conferences. We have learnt a lot, especially on how other countries are working to improve maternal health. In Kenya, during the 3rd ICM – Africa Regional Conference held last year, we won the bid to host the next Africa Regional Conference to be held in 2016. That is quite significantly big for Lesotho.
LT: Congratulations. So how far are you with the preparations?
FM: Unfortunately, we are very behind and also worried that we might disappoint the international community. The biggest challenge is we do not have an office to operate from, particularly in the run-up to 2016. If only we could get an office or a corner somewhere to run our preparatory operations, we would be grateful.
