In celebration of this week’s UN MDG Summit, the Millennium Cities Initiative interviewed a number of “MDG Heroes” – individuals working hard to advance the Millennium Development Goals in our Millennium Cities. The following is an Interview with Dr. Kwasi Yeboah-Awudzi, Director, Kumasi Metropolitan Health Directorate, about his successful campaign to reduce maternal mortality in Kumasi, Ghana.
A recent report published by the World Health Organization, the United Nations Population Fund, the United Nations Children’s Fund and the World Bank found that the number of women dying due to complications during pregnancy or childbirth decreased by 34 percent from 1990 to 2008.(1) There’s no doubt that progress has been made in reducing the Maternal Mortality Ratio (MMR), Target 1 of Millennium Development Goal 4, yet much more needs to be done, particularly in sub-Saharan Africa.
In the Millennium City of Kumasi, Ghana, the MMR was on the rise until 2009. But a sustained and dedicated effort on the part of the Kumasi Metropolitan Health Directorate and its director, Dr. Kwasi Yeboah-Awudzi, has resulted in dramatically reduced maternal deaths over the last 18 months. Dr. Yeboah-Awudzi’s direction included upgrading frontline facility infrastructure to accommodate safe deliveries, performing more cesareans at these facilities and intensifying public education regarding the importance of ante-natal visits. MCI recently asked this MDG Hero about his work; his responses are provided below.
In 2008, Kumasi’s MMR was 397 out of 100,000 – a figure that had risen from 2007 levels. What do you believe were the primary reasons for this rise in the MMR?
There was a rise in the MMR of Kumasi from 2006 through 2008. I believe this was due to the fact that people relaxed in their efforts to get maternal health improved. Within that period, there was an issue of poor referrals and inadequate infrastructure. Kumasi hospitals were not performing Caesarean sections because of inadequate equipment.
Is there one factor in particular that you believe plays the greatest role in maternal mortality (e.g., unsafe abortions, infection, obstructed labor, inadequate facilities)?
Not really so. We cannot be specific as to one particular factor. Among the direct causes of the deaths, the leading causes have been haemorrhage, septic abortion, ruptured uterus (from obstructed labour), and eclampsia.(2) While haemorrhage was the leading cause years ago (2005/2006) of late (2008/2009), eclampsia has been on top of the list of causes of death. An insufficient number of well-equipped facilities also plays a role.
However I must admit that the single key underlying factor is EDUCATION. So far as people do not have the basic education, they find it difficult to appreciate danger symptoms and signs. Hence they will always respond late to these symptoms and threats.
What role can family planning play in reducing MMR? What has the Metro Health Directorate done in this area?
Family planning can play a leading role in reducing maternal deaths if we can improve the acceptance rate. Kumasi Metro is doing its best to increase family planning acceptors, but the results are not encouraging. We need more support in that area.
The World Health Organization recommends malaria interventions with pregnant women. What role has malaria played in the MMR? Is this an area of focus for the Kumasi Metro Health Directorate?
Malaria used to play a leading role in MMR in Ghana several years ago. Of late, because of the interventions put in place by the National Malaria Control Programme, Malaria is NOT among the leading causes of maternal deaths especially in Kumasi. Pregnant Mothers are given free insecticide-treated nets (ITN) when they attend ante-natal clinics. Under the Malaria Control Programme, pregnant mothers are also given sulfadoxine pyrimethamine tablets as prophylaxis against malaria in pregnancy. The Kumasi Metropolitan Health Directorate is involved in all these programmes.
Kumasi’s MMR fell by nearly 20% in 2009, and projections for 2010 show that it should continue to decline. To what do you attribute this success? Do you believe it was the result of a couple of key interventions, or the implementation of a comprehensive strategy? Please elaborate.
The achievement of Kumasi in reducing maternal deaths is worth the attention it is receiving. The success is a result of a number of interventions of which I can only mention a few here. Measures taken include: i) Improving utilization of the findings of the Maternal Death Audit. These findings are discussed at Maternal Death Conferences, and the lessons emanating from these discussions are now being utilized in the facilities; ii) Auditing maternal deaths at all levels, and holding people accountable for maternal deaths (3); iii) Improving referrals; iv) Improving collaboration between Metro Health Facilities and the Teaching Hospital; v) Medical superintendents of the hospitals took up leadership responsibilities in ensuring that maternal deaths are prevented. They committed themselves to operating in improvised theatres. Some are using domestic fridges as blood bank refrigerators. Of course, they did that under my leadership.
I realize that a public education campaign regarding the importance of ante-natal visits played a role in reducing Kumasi’s MMR. Can you please describe more specifically how the Metro Health Directorate has educated the public? Did you educate men/fathers?
Education has played an important role in this achievement. This was done mainly at the ante-natal clinics. On a few occasions community durbars (where men had been involved) were organized, and some education was done on radio. But these (durbars and radios) have not been intensified, because of inadequate funding.
What type of education outreach was directed to the sub-metro facilities? What about trainings for medical professionals?
Topics for outreach education have centered on the importance of attending ante-natal clinics and the need to deliver in health facilities. Trainings for various categories of health professionals have been organized periodically, but they are not as regular as we (would hope).
I understand that one of the measures taken by the Kumasi Metro Health Directorate to drive down MMR has included implementing a system that guaranteed better reporting and instilling a culture of accountability. What steps did you take to encourage the sub-metro district hospitals to do this?
This was done through an important series of leadership trainings that were organized by the Regional Health Directorate. All the heads of the main units of the hospitals participated in the leadership training. After going through the training, leaders in the institutions and those at the units became ‘more responsible’ in their activities. I also demanded accountability from them, and that was the turning point.
Increasing access to skilled health care workers can play a significant role in the reduction of MMR. What steps have you taken to increase access? Has it involved training more community health workers or midwives?
Yes, we are trying to get more midwives. But more importantly, we have improved our collaboration with the private clinics and hospitals. We give them support in the form of training and some logistics. In this way mothers who do not want government facilities still get quality care from the private sector.
I understand that cesareans are now performed at frontline facilities. How did this transition occur? Was extensive training involved?
Yes that transition has been a major contributor to the reduction of MMR. At first, all cases needing cesarean section were transferred to the teaching hospital. The teaching hospital is also not all that free. Congestion almost always makes it impossible for them to attend to all emergencies at the same time, if there are more than two. Hence, emergencies could also wait there for theatres to be free! When the metro hospitals started performing cesarean sections (in improvised theatres, though), it improved the MMR.
I understand that the health care facility infrastructure has needed to be upgraded to accommodate safer deliveries. Can you please describe more specifically what this has entailed? Have these improvements been completed?
Even though we have emphasized the need for improvement in infrastructure in the facilities, this area is where progress has been very slow. The only improvement in infrastructure is the innovative use of a domestic fridge for storing blood for transfusions, at Suntreso Hospital. The Metro Assembly has just completed the construction of a female ward. Hopefully, this will contribute to reducing MMR, because the hospital will be able to admit urgent cases that require proper care.
Given that Ghana’s new insurance scheme covers a full complement of ante-natal visits, how much do the supplementary costs involved with getting proper health care (for example, transport, medical tests, other fees) continue to play a role in an expectant mother’s decision to seek ante-natal care, or to deliver at a properly prepared health facility?
I must say the National Health Insurance Scheme has contributed a lot toward improving maternal care, including the reduction in MMR. I think the supplementary costs are not so much a problem in the city as compared to the rural districts.
What more can be done to continue to reduce MMR? Is there any one thing that you believe will make the greatest impact (e.g., safe blood storage refrigeration)?
Much more needs to be done to improve the modest achievement:
a) We need properly-equipped operating theatres. (In some hospitals, like Suntreso, we have to construct a theatre.)
b) We need to provide proper blood transfusion services in all the facilities.
c) Professional staff, especially medical doctors with inclinations toward maternal health, are lacking, and we need to improve that.
d) Regular in-service trainings are needed.
It seems donors are more interested in providing consumables than in supporting the construction of essential infrastructure. Let us hold the bull by the horn, and take vigorous actions to sustain the gains.
(1) World Health Organization (2010). Trends in Maternal Mortality: 1990 to 2008. (Geneva, Switzerland: WHO, UNICEF, UNFPA and the World Bank), p. 1.
(2) A toxic condition that may develop during the last several months of pregnancy; symptoms include convulsions, abnormal weight gain and high blood pressure.
(3) In discussion with MCI, Dr. Yeboah-Awudzi explained that he had instructed all medical personnel that they would be accountable for the outcomes for any mother who had been under their care at any point in the course of her labor/delivery/post-partum, even if she was later transferred to a different facility. He maintains that this sense of responsibility occasioned more thoughtful referrals and, on a number of occasions, the decision not to transfer, but rather to deliver immediately, via cesarean surgery, right there on the premises.