Lowering Preventable Stillbirth Rates Through Midwife Training and Maternity Clinics in Djibouti Africa
Djibouti is a country in East Africa which is mostly French and Arabic speaking. Around 890,000 people live in this dry, desert region. Though Djibouti has in fertile land and few crop, it had a major economic center in the capital of Djibouti city due to Suez Canal shipping activity. Djibouti also lies in a key center between Africa and the Middle East making it a prime location for many military bases. (Djibouti Country Profile). Djibouti is a poor country with high rates of illiteracy, unemployment, and childhood malnutrition. Typically, the men work in livestock, fishing, business, military, or at the port, while women work in the home or in the informal sector as civil servants. Children seldom attend school and instead assist their families in economic activities. (Djibouti) It is also a very urban country with over 75% of the population residing in the capital, Djibouti. Rural populations rely on nomadic farming, and move move frequently for lack of food and fertile soil. It also has not rained there in four years so it is a very dry desert climate. Thus, people may lack the appropriate amount of water, as well as nutrients from crops in their diet. Because of the dry infertile soil of Djibouti, more than 80% of its food and other products are imported from nearby countries or Europe. (The World Factbook) Healthcare in Djibouti is extremely limited, especially outside of the capital city, due to poor infrastructure, equipment and supply shortages, and a lack of trained medical professionals. There are three private hospitals in the country, 4 public hospitals, and several clinics throughout the country. Most of the hospitals are clustered in the capital (shown in the image below), leaving rural areas with few options for healthcare. Additionally, the three private hospitals require out of pocket expenditure. The four public hospitals offer free healthcare, but there is such a deficit of medications people usually have to pay for it themselves at a private pharmacy. Therefore, many impoverished people do not go to the hospital because they would have to pay anyway for treatment. (Djibouti Health Insurance)
World health organization (WHO) defines stillbirth as a baby born dead at 28 weeks of gestation or more with a birth weight greater than or equal to 1000g and length of 35 cm or more (Aminu et al). Not all stillbirths can be prevented, but there are things that health professionals advise like stopping smoking, avoiding alcohol and drugs, attending all prenatal appointments, maintaining a healthy weight during pregnancy, protecting against infections, and keeping track of movements or any other concerns (Stillbirth – Prevention). However, many of these preventative measures are available for developed nations and many developing nations lack things like prenatal care or routine appointments. Worldwide 2.6 million stillbirths occur, 98% of those occurring in low and middle income countries, and over half in sub-Saharan Africa (Stillbirths). As of 2016 Djibouti had one of the highest rates of stillbirths in the world with 35 out of 1000 resulting in stillbirth, and about 850 stillbirths per year, which is significant with such a low population size (UN World Health Statistics). In Djibouti, as well as other countries, stillbirth is typically caused by a lack of prenatal care, home delivery, teenage pregnancy, prolonged labor, multiple fetuses, improper nutrition, and a lack of healthcare professionals. Also, due to the poor healthcare system in Djibouti it is hard for women in poverty to go get prenatal care because there is a severe lack of technology, trained professionals, and medications that can help with the process. Additionally, Djiboutian diets usually consist of flatbread, stew, and meat and lack fruits and vegetables. Many studies for stillbirth have linked a lack of proper nutrition to stillbirth because the fetus does not get enough food from its mother to survive. In society stillbirth tends to remain hidden and women are encouraged to forget the stillborn baby and try to have another child. The women may become isolated and suffer abuse over the issue because the women are typically blamed for the death as if it were a punishment from god for things they may have done wrong. (McClure and Goldenberg) These harmful misconceptions need to be addressed by raising awareness about what stillbirth is and what it may be caused by.
Every Mother Counts
Every Mother Counts is a non-profit organization dedicated to making pregnancy and childbirth safe for every mother in countries like Malawi, Indonesia, Congo, Tanzania, Haiti, India, the United States, Uganda, Bangladesh, Syria, and Guatemala. What they do is provide access to maternal healthcare, basic medical supplies, and skilled birth attendants. Additionally, they provide transportation vouchers so that women can get to clinics, they provide cell phones so that mothers can communicate with healthcare workers during pregnancy and childbirth, they provide training for birth attendants, provide access to family planning and education of things like HIV, STDs, and causes of infant mortality, and finally they provide proper supplies and equipment so that women get the appropriate care they need. (Every Mother Counts) Adopting the model of Every Mother Counts in Djibouti can help reduce stillbirth. It will be necessary to do many of these things in preexisting clinics in Djibouti so that they will be staffed with trained professionals and be equipped with all the proper tools to have safe pregnancies and deliveries.
Because the rates of stillbirth in Djibouti are so high due to preventable things like nutrition deficiencies, or a lack of prenatal care, maternal and infant health care will need to be improved in hospitals, and mobile clinics will be sent to rural areas, and impoverished areas where access to hospitals are low. In the hospitals and with the mobile clinics women will be educated on safe birth techniques, given medical screenings, and will be provided with an appropriate amount of prenatal vitamins and caloric boosters to supplement their diets and support their growing fetuses during their entire pregnancy. This plan will likely take place over the course of 5 to 10 years because of limitations in health care professionals, money, and infrastructure to build up.
Eradicating all cases of stillbirth may not be possible, but half of future stillborn deaths can be prevented by providing basic prenatal care and better health monitoring pre-labor and during childbirth.
Phase 1- Midwife Education
The idea is to provide midwifery and obstetric training, so that people can learn proper medical techniques and screening practices for free. Training will take place at the Dar –Al Hanan hospital in the city of Djibouti, and at the smaller maternity clinics in each district. The idea will be to have one maternity training center at each of the main maternity clinics. Busses and some type of road system will be set up so people can have some form of transportation to the clinics for training. The cost of training for the people working at the clinics will be covered again by donations or grant money in order to encourage people to be trained even if they lack money.
Following the model of Seed Global Health medical and nursing volunteers from developed countries will be matched with their equivalent in Djibouti and they will work and train alongside each other. Seed Global Health has added fifteen academic institutions for the purpose of training medical professionals, and they have gained nearly 100 volunteers in just 2 years. (Our Impact) Task shifting will be another implemented technique in training where lower-level healthcare workers, known as mid-level providers (MLPs), will be trained in some of the tasks that higher-level workers perform so that there will always be someone available who is trained in each field. The staff will get two to three years of specialized training in things like anesthesia, emergency obstetric care (like removal of the placenta, and neonatal resuscitation). Following training of MLPs in Tanzania, several studies showed that “during a one-year period, 84% of cesarean sections and emergency obstetric surgeries were done by MLPs,” with no difference in patient outcomes between physicians and MLPs (Every Mother Counts).
Following this idea each of the clinics that exist in Djibouti will be staffed with two or three main doctors who have full medical degrees or training so that they can help in the medical training center and instruct others. The clinics will also be staffed with several MLPs, nurses and pharmacists.
Phase 2 – Patient Care and Education
Once there is a fully trained staff and technologically equipped checkup as well as labor and delivery ward patients will began being seen. The clinics specifically will focus on a number of maternal health care needs including family planning, nutrition, girls and women’s health and advocacy programs, education, and empowerment. Transportation options will be available for women to get to their nearest clinic and vouchers will be provided so that they don’t have any financial barrier in taking a bus to car. From rural areas, an all terrain vehicle will be used to get over rough terrain and get into town. Once women arrive at the clinic a routine checkup would include some sort of ultrasound or heartbeat finding technology, HIV/AIDS screening, prevention or management of infections like malaria, and then checking on the health of the mother with blood pressure and blood sugar testing. As an incentive for coming the women will receive small care packages that include things like insect nets, blankets, vitamins, caloric supplements (and how to use them), soap, disinfectant, and other sterile supplies in case they have to give birth at home. They will also receive a phone or other device that has connectivity to their nearest clinic in case they have an emergency and need a birthing attendant to come to their home. Women will be encouraged to return for checkups in order to get more care packages specific to each woman and her pregnancy. Safe delivery will also be emphasized so there will be a labor and delivery wing for high risk patients like young girls, women pregnant with more than one fetus, women with or at risk of preeclampsia, women who are carrying large babies, women who have had pregnancy complications in the past and women with diseases like HIV, or malaria. This will help prevent things like obstetric fistulas, and prolonged labors and will help give the mother and baby a greater risk of survival. In order to make sure all high risk pregnancies are accounted for, a healthcare worker will go out into the communities and screen women for such warning signs during pregnancy using heart rate, blood pressure, and oxygen monitors. Before moms have the baby they will be thoroughly educated on general infant care like breastfeeding, what to do if the baby gets sick, proper sleep care, and more. Other resources for women who aren’t pregnant will include education about contraception like IUDs and products that would be easy to use, as well as free feminine hygiene products like pads so that they won’t have to miss school when they are on their period. If these improved upon clinics are successful in a smaller country like Djibouti, it may be possible to spread them to other places like Nigeria or Pakistan in order to reduce stillbirth rates in these countries. Much of this will depend on government support as well as the support of many financial backers. Keeping the clinics running will require a steady stream of money and hopefully it will sustain itself once the program is up and running and there are a variety of trained professionals working in the facilities.
Many limitations of course exist for this idea. Probably the biggest is funding because it would be difficult to afford all of the supplies, fund educational programs for training medical workers, give free medical screenings and supplies to women, and perform labor and delivery operations, especially in the case of an emergency circumstance. Another problem would be infrastructure especially in rural areas where roads are lacking. This would hinder the ability for busses to run to the clinics. This might not be as much of a problem as over 85% of the population lives in the capital city, but that poses problems of its own with overcrowding of slums and lack of space. Another problem may be that women take home a care package along with all the things they are taught, but do not utilize any of what they are given due to cultural differences. They may not see the use in taking supplements or even have the water supply to take them. Additionally, due to the drought water supplies are at an all time low, which causes problems with hygiene and sanitation and can be detrimental to a mother’s and infant’s health. Because many people live in the city the clinics may become very crowded and so the existing clinic space would potentially need expansion in the future. Though there are many challenges there is great potential in increasing the availability of women to health care services in order to reduce stillbirth rates in the country.
An estimated 2.6 million stillbirths occur annually, about half being preventable. With 98% of still births happening in developing countries it is important that preventative measures are taken to reduce this rate and lower the risk of stillbirth globally. In Djibouti alone 35 out of every 1000 births result in stillbirth, and with the population being as low as it is, it is alarming the Djibouti has similar rates to places like Nigeria or Pakistan who have significantly higher population sizes. One of the biggest causes of disparity is due to the drought which has caused infertile land, low crop yield, and a lack of water. Trying to fix these issues will be very difficult but introducing alternatives to the lack of crops may be necessary through the provision of vitamins and caloric supplements. The Bill and Melinda Gates Foundation have already noted Djibouti as a country with significant problems. UN agencies and the World Food Programme have raised around $18.5 million dollars to provide aid, and food, especially to people in rural areas. Another $250,000 is being provided by WHO to provide mobile health units in rural areas, and another $100,000 has been allocated from the UN to reduce maternal and neonatal mortality rates. (Tran) Though money is being used to help, it can be seen that significantly less is being used for this issue compared to issues seen by the government and world agencies as more important. It would be possible to get funding from Every Mother Counts because they have been raising money for this cause in other countries and have currently raised over 17 million dollars through donations alone (Every Mother Counts). Since these clinics are government owned it would also be possible to get some government funding for the work we would do. Because so many stillbirths are preventable, it will be vital to get funding for this cause to save the lives of women and infants in Djibouti.
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