The number of expected pregnancies in the community and the number of facility deliveries per month are standard questions I now ask during site visits. It is not surprising to see a large discrepancy between the two estimates. In one clinic, situated in a community averaging 54 births a month, only 9-10 took place in the facility.
The extreme distances women have to travel, coupled with nonexistent infrastructure are largely to blame. Most babies also arrive quite unexpectedly. In reviewing forms at a clinic, I noticed that the expected delivery dates were recorded as entire months (i.e. November 2009). It is no wonder that babies are born on the roadside, to mothers in route to the clinic.
In addition, there is a grave shortage of providers in the rural areas. In some clinics, staff members typically responsible for maintenance and facility upkeep (no medical training) are taking on clinical duties to compensate. In other clinics, the sole provider is male, which results in cultural and gender-based barriers to facility deliveries. Consequently, many women choose to deliver the baby at home, with a trusted, yet often untrained traditional birth attendant.
Several maternal health programs in the rural communities are emphasizing ‘birth-preparedness’. Women are advised to have a plan for getting to a facility to deliver and set aside money for transportation. However, men are the decision-makers in the family and subsequently crucial players in determining whether or not women deliver in facilities. Therefore, these programs must go hand-in-hand with initiatives that push male involvement. During site visits, I have met plenty of incredibly supportive husbands and male community health workers. But I have also heard numerous stories of women dying from severe complications in home-deliveries, while husbands deliberate whether or not to organize money and transport to take them to a clinic. Even worse are complications that require hospitalization. For many villages I have visited, this means a five-hour ride on a horrible road to reach the nearest hospital. Since transport beyond a bicycle or oxcart is generally unavailable, an ambulance or district vehicle will first need to drive to the clinic and then return with the woman.
All of these delays limit chances for survival. Take for instance a home delivery with complications… first the complications (emergencies) must be recognized, which can be challenging if there is no provider or the provider is untrained. Then the husband must decide to seek facility care and organize transport, yet another delay. Then the woman will need to be transported to the facility, which could be as far as 30 km on a dirt road, usually traveling by bicycle or oxcart. Finally, if the complications are severe, it will take an additional 10 hours for the woman to reach the hospital by ambulance (and this is dependent on whether there is money for fuel). It is no wonder that the maternal mortality rate is so high…