UNICEF Madagascar: The Doctor is Out

out The doctor is in It is said that maternal mortality, more than any other health indicator, reflects the overall performance of a country’s health system. In Madagascar eight women die every day in childbirth or of pregnancy-related causes. It is a number that points to a health system stretched to the breaking point. Nowhere is this more apparent than in the rural health centres that serve 70 per cent of Madagascar’s population: they lack not only essential personnel, but also critical medicines, supplies, emergency equipment and funding. With so few resources, it falls to paramedics like Midwife Christine Razafindrasoa, the only health professional at the health centre in Ambodihazinina, a small village in the eastern district of Fenerive Est, to hold it all together.

Date 16 / 05

To do water Family planning daily reports

Midwife Christine Razafindrasoa is tired. It’s not just the up and down on the water pump. It’s everything. As the only health professional at Ambodihazinina health centre she is responsible for the health of 8,612 people in seven villages.

“I work night and day,” she says. “During the day I see patients who come to the clinic, and attend to traumas and emergencies… and then I have my regular schedule to follow: Monday it is family planning, Tuesday and Friday immunisations, and Thursday antenatal consultations. I also take care of the CRENAS (Outpatient Centre for the nutritional rehabilitation of severely malnourished children without complications) and supervise community health and nutrition workers in various villages. Every afternoon I have to fill out reports and every month I have to organize and conduct outreach for immunisations and other health activities in villages far from here. Then I have to complete and send my monthly report to the district. During the night I have to take care of emergencies: it is not unusual to see three or four cases a night that involve accidents or fights, in addition there are women who started giving birth at home, and were brought to me in the middle of their labour when they developed complications. It seems I am always multi-tasking — going, going, going from one thing to the next.”

While Christine may be alone at the health centre, she is certainly not alone in facing this situation. “It’s the same everywhere,” she says, “so it’s no use complaining. There aren’t enough trained professionals, so we just have to continue working like this. There have been times when I thought I couldn’t go on. I remember one particular day when I was so tired I fell asleep in the office. It was during an outbreak of dengue fever and many people were sick. I was also feeling sick. In the evening a family came with a woman who was about to deliver.

They knocked on the door. At that moment I thought it was beyond my ability to wake up and deliver that baby, but I had to do it. I had no choice. This job can be overwhelming, but it is important. People need me.”

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Date 19 / 05

To do Antenatal care sessions daily reports organize vaccines for measles campaign

This morning Maureen is the first to arrive for an antenatal care checkup. Now five months pregnant, she has walked seven kilometres to attend the second of four recommended antenatal checkups. However, she has no plan to come to the clinic for the delivery. “My village is too far away,” she says. “I’m afraid I would give birth on the way.”

Like Maureen, over half of Madagascar’s population lives five kilometres or more from the nearest health facility — in remote areas inaccessible by a car or even a motorcycle. This means when it is time to give birth most women follow tradition.

“Women are used to delivering at home with a traditional birth attendant (TBA),” Christine explains. But delivery with TBAs can be risky for both mother and child.

Statistically, 15 per cent of all deliveries will run into life threatening complications requiring emergency obstetric care. If something goes wrong all the TBA can do is load the woman onto a makeshift stretcher and have people carry her to the health centre. “I have no idea how many women die on the way,” she says, “but I can tell you that, without a doubt, the number one cause of maternal mortality is arriving late at the health facility with complications.”

Even if they manage to make it to the health centre in time and find Christine there (she is often away doing outreach or taking care of other medical business) she cannot always help. “For example, if they need a cesarean section, I can’t do it,” she says. “I have to refer them to the district hospital in Fenerive Est, which is 25 kilometres away — at least five kilometres on foot followed by a 20 kilometre ride in a bush taxi on a dirt road.” Assuming the woman makes it there alive it is possible that even the hospital may temporarily lack the personnel or the supplies to perform the operation.

Christine explains that all of these factors point to the great importance of antenatal care. “Not only can we ensure mothers are eating properly and getting the medicines and vaccinations they need to prevent illnesses and other problems, we can also identify the difficult cases early. This allows those mothers to get the help they need before they run into serious trouble.”

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Date 19 / 05 continued

Next, Christine calls in Violette. She is three months pregnant and this is her first checkup. Violette was referred to the clinic by Brigitte, a Community Health Worker in Ambodihazinina. “Brigitte heard that I was pregnant so she came to my house to talk to me about going to the health centre for antenatal checkups,” Violette explains.

Violette did not need convincing. In 2008 when her sister Tina was pregnant Brigitte came to check on her sister every few days. She made sure Tina attended all of her antenatal checkups, taught her about proper nutrition during pregnancy and encouraged her to deliver at the health centre.

But all of this couldn’t prepare the family for the ‘complications’ that arose the night Tina went into labour: Cyclone Ivan, a powerful category four storm, hit the island, making landfall in nearby Fenerive Est. “During the cyclone my sister went into labour,” Violette says. “We carried her to the health centre. It had been destroyed. But with the midwife’s help, she gave birth on the ground at 4 am. The midwife kept them there for a few hours to be sure they were both okay and then helped them back to what was left of our house. She helped Tina and the baby get settled before she returned to the clinic. Over the next couple of days she continued to visit and check up on my sister and the baby as often as she could.”

While it is unlikely that Violette will experience the same ‘complications’ as her sister, she knows that things can and do go wrong during pregnancy and delivery, and today’s visit to the clinic has left her feeling reassured. “Today the midwife checked my abdomen and measured it, she checked my eyes and my ankles and she gave me some medicine. It feels good to know that everything is okay.” When the time comes Violette plans to deliver in the health centre. Her only fear is that with everything Christine has to do, she may not be there when Violette needs her most.

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Date 20 / 05

To do immunisations monthly reports order medicines

“After Cyclone Ivan I was busier than ever,” Christine says. “The most difficult thing was doing deliveries. There was no space. I had to do them on the ground. And after four hours, if there were no problems, I would send mother and baby home. In the month after the cyclone I did ten deliveries this way. Fortunately all of them were normal and everyone was fine.”

UNICEF provides additional training to paramedics and places them in overstretched health centres across the country. With so much need after the cyclone, Christine was relieved when they sent a nurse to help. “She and I worked together for two months. During that time we were seeing 200 patients a day. There was no way I could have helped them all without her. You have to understand, when it comes to cyclones the main cause of death is not the cyclone itself, it’s the illnesses that come afterwards: malaria, diarrhoea and pneumonia. Many houses were destroyed so people had no way to protect themselves from malaria. Without safe water and proper hygiene, people who already lacked sufficient nutrients got diarrhoea. For many, living outside in the cold and rain resulted in pneumonia.

“A few weeks after the cyclone, the community built me another clinic. Like the old one, it was a small house made of bamboo with a thatched roof. Over time UNICEF had provided the clinic with delivery kits, a stretcher, a delivery table, medicines and a refrigerator. With all of it crammed into that tiny room there was no space for me to move. And in another cyclone, I knew that clinic too would be lost.

“I was so grateful when UNICEF built this new clinic. It has had a huge impact on the quality of care that I am able to provide. There is much more space, which makes everything easier. I have a room for consultations and deliveries, an office, a storeroom for medicine and supplies and a room with two beds — so I can keep an eye on mothers who had complications during delivery and their babies. There is also a pump, a tank on the roof, and a water filter, so I now have access to clean water.

“Working in this new clinic I feel a lot more motivated. And it’s really good to know that this one will remain standing in the next cyclone — so I will be able to provide the help my community needs when they need it most.”

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Date 23 / 05

To do order medicines family planning monthly reports organize outreach

As happy as she is in the new clinic, Christine’s work is still hampered by a lack of essentials “...like electricity,” Christine laughs. “You might be surprised to learn that it isn’t easy delivering babies by candlelight.” But it is actually the clinic’s refrigerator that poses a bigger problem: vaccines must be kept cold or they will cease to be effective. However, severe cuts to the health budget mean Christine can no longer afford the 30 litres of petrol she needs each month to keep the refrigerator working. This is having a direct impact on the services she can offer — and on the health of the communities for which she is responsible.

“Every time I organise immunisation activities I have to collect vaccines from the nearest health facility with refrigeration, which is 25 kilometres away in Fenerive Est,” she explains. “I then have just 48 hours to vaccinate people with that stock before it becomes useless. This makes it impossible to provide immunisations as often as I am supposed to.”

Add to this the fact that aid money that used to finance outreach activities in remote communities — including immunisations — has been suspended since the beginning of the crisis, and it is clear why nationwide vaccination coverage for preventable diseases like measles, has steadily declined since 2009.

The clinic’s medicine cabinet is as empty as the refrigerator. Christine orders new stock every two months and sends a community member to Fenerive Est to collect it. “Sometimes he arrives at the government pharmacy to find that the director isn’t there, or that the medicines are not available,” she says. “Like Iron folate.

It is essential for pregnant women, but for the past six months it has been out of stock at the government pharmacy, so I have been buying it from a private pharmacy and providing it to mothers at a cost.”

But even that is too costly for some. “Around here people’s main sources of income are coffee and cloves,” Christine explains. “During the crisis the prices for these have been low, so people are earning less. Now people cannot always afford to buy all of the medicines they need.”

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Date 25 / 05

To do Meeting with health inspector organize outreach

When she hears the motorbike pull up outside the health centre Christine goes to the front porch to greet Honoré Andriatsiva, the Chief of Public Health for the district. As he does on these twice-yearly visits, Andriatsiva looks over Christine’s reports and asks how things are going. When Christine tells him about some of the difficulties she’s facing he is sympathetic, but there is not a lot he can do. He has problems of his own. The government’s health budget for the district — one of the wealthier districts in the country — has been cut in half. It now stands at just 84 million Ariary (US $ 42,520) or 227 Ariary (US $0.11) per person.

Prior to the political crisis, not only was the government’s contribution to the health budget greater, the addition of foreign aid put the average district health budget at US $8 per person per year. That figure is now just US $2 per person per year. This has real consequences for the health of the population.

“Bednets are just one small example,” says Andriatsiva. “We have lots of bednets at district level, but no funds to dispatch them. It’s not the kind of work I can do on my motorbike: one load of bednets weighs 40 kg, and a health centre this size would need seven loads. The same is true for cool boxes and emergency drugs.”

Another example is the closing of health centres. “Two were recently closed in this district,” Andriatsiva says. “One because the paramedic left and the other because the paramedic died.” Without replacements, the 29,000 people served by those health centres must now travel 40 kilometres to reach the nearest health facility.”

“Fortunately UNICEF is helping us to address personnel problems by recruiting paramedics for health centres,” Andriatsiva says. UNICEF is also helping to support the health system by putting systems in place to ensure the availability of essential medicines, helping to fund vaccinations and outreach and providing the equipment, supplies and training to ensure mothers and their unborn children have access not only to antenatal care but also to life-saving emergency obstetric and newborn care.

“The health of the population is our priority,” says Andriatsiva. “Managing everything with this reduced budget is difficult, but we are in a crisis here and we just have to do the best we can.”

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To provide quality services to the communities in their care, and to prevent stubbornly low health indicators — notably maternal mortality — from rising still further, health centres in Madagascar need consistent access to essential medicines, supplies, emergency equipment, and trained personnel.

While the international community remains unable to work directly with the government, UNICEF is working alongside local authorities to fill the gaps in Madagascar’s overstretched health system and to ensure that funds are invested and targeted to directly benefit mothers and children.