Tsitsi Matope
The Ministry of Health has come up with various strategies to ensure safe motherhood in Lesotho.
According to the Demographic and Health Survey (DHS) of 2009, maternal mortality has increased to 1 155 per 100 000 live births compared to the DHS 2004, which was 762 deaths per 100 000 live births.
According to the Ministry of Health, these alarming deaths mostly occur after delivery and are mainly caused by severe bleeding.
In an interview last week, the Ministry’s Sexual and Reproductive Health Manager, Ms Motsoanku Mefane outlined the interventions that have been planned in an effort to improve the health of mothers and babies and to reduce maternal and neonatal mortality.
According to the United Nations Maternal Mortality Estimation Inter-agency Group, which consists of representatives from the World Health Organisation (WHO), United Nations Emergency Children’s Fund (UNICEF), United Nations Population Fund (UNFPA), United Nations Population Division, the World Bank and world renowned academicians, maternal mortality is:
“The death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”
LT: You are introducing a new set of strategies aimed at reducing maternal deaths. What do you believe made previous efforts not as effective as had been expected?
Mefane: Firstly let me explain that our indicators have reflected that deliveries at health facilities have increased from 59 percent in 2004 to 62 percent in 2009, while we know that more women are now seeking antenatal care services (antenatal care is the regular medical and nursing care recommended for women during pregnancy) as seen from the 98 percent increase in 2009 compared to 91 percent in 2004.
On the other hand, the use of contraceptives also increased from 37 percent in 2004 to 47 percent in 2009.
The need for family planning is at 23 percent and we still have concerns in the rural areas where access is a challenge.
However, while the indicators show an improvement, what is worrying us is the high maternal mortality.
That is why, this time around, we decided to critically look at ourselves and our systems in order to get it correct.
Quality issues in relation to sexual and reproductive health services need to be addressed seriously.
LT: So in short, the problem is poor service which is causing this high maternal mortality in Lesotho?
Mefane: Yes; the painful reality is that women are dying because of poor-quality care especially after delivering in health facilities.
Another factor is the inaccessibility of health services.
Because mothers walk long distances, it is difficult for them to regularly visit the clinics and have complications diagnosed early.
LT: What other measures is the ministry putting in place to ensure mothers and families, even those living in hard-to-reach areas, see it worth their while to brave the difficult journeys to the clinics where you are saying the service, at some health centres, is not good enough?
Mefane: We are soon piloting the performance-based finance project in Quthing and Leribe.
This new initiative will help us ensure accountability among all stakeholders involved in the running of health services at all levels of care.
We would want midwives to pull up their socks and commit themselves to delivering quality service.
The project will need the commitment of District Administrators, District Councils, Health Centre Committees, Public Health nurses and community health workers.
LT: What is unique about this project?
Mefane: What is unique is that all these stakeholders involved will sign contracts as a way to prove their commitment to effectively play their different roles.
Their roles are meant to ensure quality care, selected indicators such as facility-based deliveries, antenatal care and immunisation, to mention but a few.
Health workers will be rewarded or paid incentives based on their performances.
We have noticed a worrying trend whereby some health workers don’t perform at the expense of others simply because they know they will still get the same salary.
It is against this background that the government has committed M4 million towards this project, with the view of providing incentives to health workers and community health workers who have a conscience and would like to work hard in order to be rewarded.
LT: So how is it going to work and when can this project be introduced to other districts?
Mefane: The roles of all stakeholders are clear, for instance, community health workers are responsible for tracking the sick and pregnant women for antenatal care.
They bring or encourage them to go to health facilities.
They have to devise ways to ensure mothers deliver at health facilities and that after delivery, they go back for postnatal check-up, so that their babies get vaccinated.
Their incentives would be based on how they perform their duties against what the statistics will be telling us.
In terms of the health centres, different amounts of incentives will go to the staff.
They will then need to develop tools that would ensure every midwife does what she is expected to do.
We expect these tools to assist them in identifying who, among them, is pulling the facility down and endangering the lives of mothers.
We expect the project to be soon rolled out in phases in other four districts by 2015.
LT: What is going to happen to those who will, for whatever reason, fail to meet their obligations?
Mefane: This is an issue that the ministry is currently looking at to see how such a challenge would be addressed, especially where a midwife’s incompetence can cost the lives of mothers and babies.
LT: Are there any efforts towards grooming midwives to help them improve their performance? Some might lack adequate health facility experience.
Mefane: The Sexual and Reproductive Health and HIV Mentorship Project in the 10 districts will help to build the capacity of the midwives in the health centres.
Each district will have one mentor who, because of their vast experience, would train the midwives in identified weak areas.
They are also going to assume the role of advisors to the health facilities.
We are expecting them to help minimise emergencies because they would have taught the midwives the importance of taking certain steps and precautionary measures that would ensure safe motherhood.
LT: Will one mentor per each district cope with the demand to ensure standards are improved in all the health facilities?
Mefane: There are other 10 midwives undergoing advanced midwifery training at the University of the Free State.
After their graduation in 2015, another group of 10 midwives would also be enrolled for the same training.
The training programme is being supported by the World Bank.
These midwives will also come and strengthen the Sexual and Reproductive Health Programme.
LT: Are the graduates in the current group going to be placed in the 10 districts? How is it going to work?
Mefane: Yes; our expectation is that they will be distributed to the 10 districts where other mentors are already working.
LT: If you are getting training support from the World Bank, how are you making sure other local stakeholders fully participate in the fight against maternal mortality?
Mefane: We have launched a resource-mobilisation project under the Millennium Development Goals Acceleration Framework.
We started last year to invite various stakeholders who included other ministries, civil society organisations and Non-Governmental Organisations (NGOs) to say, ensuring safe motherhood and the survival of babies is not our responsibility alone.
This is because we need the support of other sectors in order for us to reduce the death of mothers and children.
For example, roads are needed to enable patients to easily access health centres.
We need telecommunication networks to improve our communication and among others, we also need a vibrant agricultural sector in order for the mothers and children to eat well.
LT: Let’s talk about one innovation some NGOs have invested in, the mothers’ waiting lodges. There are reports that all is not well with this initiative. What are the challenges?
Mefane: In some areas, the waiting mothers’ lodges are too small while the issue of how we can feed the women is also another challenge in many areas.
We are getting a lot of support in the form of blankets and mattresses, which we received from WHO and food packages from the World Food Programme.
However, food-donations cannot, in the long-term, resolve the challenges around feeding.
As a result, together with assistance from the Ministry of Agriculture and Food Security, we have initiated food-production programmes at some health centres such as Ha-Mokoto, Sehong Hong, St Teresa and Mohlanapeng and Linakeng in the Thaba-Tseka district to help improve nutrition in these clinics.
Before the end of this year, we hope this initiative would be replicated in Qacha’s Nek and Mokhotlong.
LT: What other unique innovations have you introduced or are you planning to introduce to help deal with the problem of accessibility?
Mefane: We do see the need to provide services to communities in the hardest-to-reach areas where there are also no health centres.
What this means is we need to devise sustainable mechanisms that would see us bring comprehensive services to these communities.
We are talking family planning, drug refills, immunisations and HIV testing and counseling among other services.
We are currently mobilising communities through their local community structures’ leadership to understand that they can also provide solutions to their challenges.
By providing a house or room that can be turned into a health facility and be used by the outreach nurses, this can help ease the challenge of lack of infrastructure in many remote areas.
We have managed to establish such outreach points in some areas but sustaining them is also largely dependent on partners.
We would like the Ministry of Health to commit itself to running these outreach services, in order to ensure sustainability.
A lot of people including pregnant mothers from the helicopter sites are dying from ailments that could have been treated if services would have been provided.
Another innovation we would like to introduce and sustain is to ensure all centres provide a One-Stop-Shop service.
This simply means people who come for a certain type of service are also able to access other related or complementary services.
For example, when a mother comes for family planning, a facility should take this opportunity to provide other services such as immunising the baby, test for HIV and make other medical checks.
LT: What if the health centre cannot provide some services such as family planning as is the case with all Roman Catholic health facilities?
Mefane: We are looking at partnering with other organisations that provide family planning services to establish amenities near such religious facilities to address the unmet need for family planning.
In such areas, we also rely on local, community-based distributors of family planning products to help bridge the gap.
