Saving mothers’ lives in Namibia Namibia’s ongoing efforts offer lessons for other countries seeking to improve maternal health, as well as for health programs tackling HIV/AIDS, malaria, tuberculosis, or other conditions. 103 Kathleen Up to a half a million women die each year Preventable tragedies McLaughlin, around the world because of complications The global health community has long Marc van Olst, and arising from pregnancy or childbirth. The understood that improving the health of women Ronald Whelan, MD majority of these deaths occur in sub-Saharan during pregnancy, childbirth, and the Africa.1 Since they are largely preventable, postpartum period represents a massive oppor- they represent a tragedy playing out every day tunity not only to save women’s lives but also across the continent. Progress on maternal to improve neonatal, infant, and child health health there is hampered by health systems that outcomes directly. Further, most maternal are understaffed, underfunded, and over- deaths in low-income countries are preventable— whelmed—and thus too fragile and fragmented to arising largely from pregnancy-induced deliver the required level or quality of care. hypertension, hemorrhage, or sepsis. Still, up Consequently, many countries in sub-Saharan to a quarter of a million women die in sub- Africa will struggle to meet the United Nations’ Saharan Africa each year because of problems Millennium Development Goals for reducing associated with pregnancy or childbirth. child and maternal mortality by 2015.2 In Namibia, the incidence of maternal and Nonetheless, some countries are making neonatal mortality has doubled in recent years headway. Our recent work in Namibia, for (Exhibit 1). A woman in Namibia today is almost example, suggests that coordinated, targeted 100 times more likely to die during pregnancy interventions led by local stakeholders can than a woman in Europe. This difference partly accelerate improvements in maternal-health reflects Namibia’s high rate of HIV/AIDS outcomes. The key is to work with local health infection (more than 20 percent of the women at leaders to develop solutions that improve the the country’s antenatal clinics are HIV-positive) quality of health care, increase access to it, and and partly reflects limited access to health promote its early uptake. facilities (Namibia has the world’s second-lowest population density, with barely two people per The resulting interventions being pursued in square kilometer). Namibia are straightforward and practical— 1 World Health Organization improvements in the training of midwives, In a bid to stem Namibia’s rising maternal- (WHO), United Nations cheaper antenatal clinics inspired by the design mortality rate, the country’s Ministry of Health Children’s Fund (UNICEF), United Nations Population of shipping containers, operational fixes to and Social Services (MOHSS), in partnership Fund, and the World Bank, Maternal Mortality in reduce ambulance response times and wait times with McKinsey, the Synergos Institute, and the 2005, World Health at clinics, a radio talk show to educate patients Presencing Institute from the Massachusetts Organization, 2007. 2 In addition to meeting other and stimulate demand—yet are collectively Institute of Technology (MIT), established the social, educational, and powerful. A closer look at Namibia’s ongoing Maternal Health Initiative, or MHI (see sidebar, health targets, the United Nations seeks to reduce child efforts offers lessons for other countries seeking “About the initiative” on p. 110). It focuses on a and maternal mortality rates and drastically reverse to improve maternal health, as well as for health microcosm of Namibia’s health system to develop the spread of HIV/AIDS programs tackling HIV/AIDS, malaria, tuber- a replicable approach for improving maternal and malaria by 2015. For details, see un.org/millenniumgoals. culosis, or other conditions. health care across the country. 104 Health International 2010 Number 10 Health International 2010 Africa Namibia Health Exhibit 1 of 3 Exhibit 1 Maternal mortality has doubled in Namibia in recent years. Namibia’s maternal-mortality ratio, deaths per 100,000 live births 225 in 1992 271 in 2000 449 in 2006 Source: Health and Social System Services Review, 2008, Namibia’s Ministry of Health and Social Services; Monitoring Emergency Obstetric Care, 2006; McKinsey analysis The MHI chose to set up its pilot project in the mobilization, the capabilities of health workers, Khomas region, the most populous of Namibia’s and health system operations, respectively. 13 regions and the one with the worst uptake Each subteam included a variety of local front- of antenatal services.3 (Less than 7 percent of line health leaders and other stake holders—for pregnant women there receive antenatal check- instance, nurses, social workers, ambulance ups during the first trimester.) Within Khomas, drivers, and middle managers. the team focused on four of the largest suburbs of Namibia’s capital, Windhoek: Hakahana, Finally, to ensure local ownership and Katutura, Okuryangava, and Samora Machel, accountability (as well as to expand future which have a collective population of about initiatives across Khomas), a regional 80,000. It focused in particular on these areas’ delivery unit was established under the guidance busiest hospital and primary care clinics, of the chief medical officer in Khomas. It Katutura Hospital and Okuryangava Clinic, provides managerial oversight, monitors the 3 Common antenatal services respectively (Exhibit 2). performance of the region’s improvement include measuring blood pres- sure, conducting blood and in maternal health service delivery, and inte- urine tests, monitoring weight, taking fundal height measure- Next, three subteams were formed to design and grates the activities of the subteams with ments, and answering general develop prototype maternal-health solutions those of the health ministry’s regional team. questions about diet and fetal movements. for problems associated with community The subteams quickly identified and Saving mothers’ lives in Namibia 105 Health International 2010 Africa Namibia Health Exhibit 2 of 3 Where we worked: Inside the Maternal Health Initiative. Exhibit 2 Where we worked: Inside the Maternal Health Initiative. Ohangwena Omusati Oshana Caprivi Oshikoto Kavango Namibia Khomas region Kunene Otjozondjupa Total population: Most densely populated of 2,047,000 Namibia’s 13 regions Omaheke Life expectancy at birth: Region with highest Erongo 59 years (men) number of facility-based Khomas Windhoek 63 years (women) deliveries (8,915); nearly 19% of all such Total expenditure on health births in country per capita: $338 Around 7% of women get Hardap 49% of population lives antenatal checkups in the below international first trimester poverty line of $1.25 per day (2007) Karas An estimated 160,000 to 230,000 people (all ages) live with HIV (2007) More than 60% of rural population lives farther than 5 km from a health facility and cannot afford transport; pregnant women often must travel on foot to reach a health care facility Katutura Hospital Okuryangava Clinic Situated in Katutura, The busiest clinic in one of the largest Khomas 1 km communities in Khomas, Situated in the heart of with ~40% of total Katutura, the clinic’s population of the region full-time nursing comple- Klein Windhoek(~80,000 people) ment of 8 registered Largest hospital in and staff nurses attend to the region, with 400−500 ~120 patients per day beds Antenatal patients in Waiting time at antenatal- 2007: 0 care clinic: ~6 hours Note: Figures are for 2006 unless indicated. Antenatal patients in Source: World Health Statistics 2008 2007: 4,997 106 Health International 2010 Number 10 A woman in Namibia today is almost 100 times more likely to die during pregnancy than a woman in Europe implemented several interventions to improve The quality of care during pregnancy was found to the supply of maternal care in Khomas and be significantly constrained by the lack of con- to raise demand for care among local women. tinuing education as well as by apathy and poor While it is too soon to claim victory over motivation among nursing staff. Mentoring Namibia’s maternal-health problems, the results and coaching practices have gradually fallen away thus far are encouraging. as a result of staff shortages and turnover in critical positions. Katutura Hospital, for example, Supply-side interventions has only one full-time gynecologist, and doctors Improving the access of patients to quality care is there do not typically stay in the department for a vital step in improving health outcomes. In more than two or three years. Khomas, the MHI and its local partners helped to bolster the quality of maternal care and to pilot In response, the MHI subteams worked with novel ways of adding capacity to the system. They the hospital’s superintendent and with nurses and also introduced efforts to squeeze greater doctors in the obstetrics department to develop capacity out of the region’s existing health assets. and institute a skill-building program for clinical personnel. One important component was the Raise the bar on quality creation of a mentoring role so that senior nurses In Namibia, the quality of maternal care has could identify, coordinate, and offer in-service deteriorated in recent years—a fact reflected in a training for nurses and nursing students. Next, 2006 survey from the MOHSS, which found health workers at the hospital engaged with nearby that less than 20 percent of the country’s midwives private hospitals and local training institutions could reliably diagnose and manage post- to learn best-practice training and clinical tech- partum hemorrhage. Further, the ministry found niques. The team also visited training that less than 40 percent of Namibia’s midwives institutions in Cape Town, South Africa, where its correctly monitored women in labor. What is more, members met with colleagues who had developed the MHI team observed that, not uncommonly, a best-practice curriculum and training manuals more than five different midwives attended for midwives.