The Gambia
In 2006 Maternity Worldwide carried out a comprehensive assessment into maternal health and the challenges to reduce maternal mortality and morbidity in the Central and Upper River Divisions, The Gambia. Current maternal health service provision was evaluated against international standards and recommendations were made to improve women and girls’ health, women and girls’ status and maternal health care provision in Central and Upper River Divisions in order to reduce deaths in pregnancy and childbirth.
The report highlighted a number of areas for improvement and steps that should be taken to reduce maternal mortality and morbidity in CRD and URD. Addressing these issues will require collaboration between all stakeholders including government, NGOs and the population of CRD and URD themselves. The recommendations below include general points that are applicable to all stakeholders, and specific recommendations that could be implemented
Recommendation 1: Increase Comprehensive EmOC Facilities
There is insufficient access to Comprehensive EmOC services in CRD and URD. There is only the Bansang Hospital that provides this service and, for the residents north of the river, access to the hospital is limited by the river. According to definition, Basse and Kuntaur Major Health Centres should be providing Comprehensive EmOC but instead Basse provides only Basic EmOC and Kuntaur is barely functioning.
Recommendation 2: Capacity: Recruitment and Retention of Staff
There is a lack of qualified staff to perform essential functions especially caesarean section. There are too few doctors, nurses and midwives and many staff are exhausted by onerous rotas. Inadequate salaries, poor working and living conditions perpetuates a high attrition rate of staff.
As highlighted by the report there is a severe shortage of skilled health care providers throughout The Gambia. The national shortages of health care staff are reflected in the difficulty in recruiting and retaining obstetricians, anaesthetists, midwives and nurses to work in CRD and URD. Although it might be possible in the short term to incentivise skilled staff to work in CRD and URD (by offering higher salaries or other benefits) this will do little in the long term to increase capacity and would simply be to the detriment of other regions in the country.
Recommendation 3: Equipment and supplies
Health care facilities should be improved and equipped to provide signal EmOC functions and ensure satisfactory working conditions to retain staff.
Recommendation 4: Fuel and water supplies
Until the rural electrification scheme is completed, healthcare centres will be dependant on generators to provide electricity and also to pump water to water storage tanks. Not only do generators require fuel, but the ambulances for providing transfers are also dependant on a continual supply.
Recommendation 5: Maternal death and ‘near miss' reviews
Further information should be gathered on the factors underlying maternal deaths in CRD and URD to ensure that activities to reduce maternal mortality and morbidity address each of the key issues.
Recommendation 6: Data collection
The quality of reporting of maternal morbidity and mortality should be improved. Each health care facility has a logbook of all births and obstetric cases managed at the facility but there has been no audit to ensure accurate reporting. This record should contain sufficient information on the diagnosis, management of the case and outcome (both maternal and fetal).
Recommendation 7: Community education programme
All providers should incorporate information on maternal health and the recognition of obstetric emergencies into existing community education programmes. Of particular note is the emphasis of traditional birth attendants (TBAs) to refer properly at times of complications. Once quality of EmOC services and access to skilled attendants improves, encouraging women and girls to use health facilities for deliveries may become a component of community education.
Recommendation 8: Safe Birth Fund
One of the barriers to receiving EmOC in CRD and URD is the cost of transport and treatment. The long term the goal should be to provide universal access to maternal health care that is free at the point of delivery. In the short term steps should be taken to prioritise affordable care for the poorest in society. One approach is the use of a voucher scheme to provide subsidised medical care. Although the evidence base is weak, there is some evidence that voucher schemes can be used to improve targeting of vulnerable groups.
Recommendation 9: Women's groups and women's empowerment
Community development and women's empowerment programmes need to be developed that focus on income generation, breaking down gender roles and decision-making capabilities of women and girls. Local government and men need to be included.
A full copy of the report is available on request.
