SKILLED CARE DURING CHILDBIRTH - Family Care International

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Skilled Care During Childbirth: Country Profiles Botswana SAFE MOTHERHOOD: STEP-BY-STEP In November 1990, a conference for the Members of Parliament and the House of Chiefs was held in Gaborone to publicise the issue and mobilise political support. At the same time, the Family Health Division of the Ministry of Health organised a workshop on communication strategies for safe motherhood and HIV/AIDS prevention. In 1992, a multisectoral Safe Motherhood Task Force was established to help develop, implement, and monitor a national safe motherhood programme. The Task Force meets regularly and includes representatives from the government, NGOs, and training institutions, among others. In 1993, two key studies were conducted to help formulate a national plan: > Safe Motherhood in Botswana: Situation Analysis which reviewed available information on the extent of maternal mortality and its causes and consequences, as well as other women’s health issues, and recommended corrective strategies; > Determinants of Maternal Mortality in Botswana: An institutional, household and community perspective, conducted by the MCH/FP Unit and UNICEF, which examined maternal mortality records between 1990–1992 to identify direct and indirect causes of maternal mortality. • Policy on Women and Development (1995) advocates adolescent-friendly reproductive health services in the context of women and development. • National Population Policy (1996) states that the individual is central to development efforts and that the goal of health and social services is “improved quality of life and living standards of all people in Botswana.” Critical Interventions to Increase Skilled Care During Childbirth A series of focused interventions have contributed to Botswana’s success in lowering maternal mortality and increasing rates of skilled care during childbirth: Developing Health Services Infrastructure Botswana has developed a well-distributed health services network such that the majority of the population (86%) lives within 15 km of a health facility. The health care system is structured along the following lines: • District/referral hospitals (1:100,000–350,000 population) have an operating theatre to perform C-sections, blood transfusions, and other advanced services. • Primary hospitals (1:12,000–35,000 population) are found in remote, low-density areas and staffed by medical officers and registered nurse-midwives. These facilities provide the same advanced emergency services available in district hospitals. • Health clinics (1:5,000–10,000 population) are staffed by registered nurses and family welfare educators (FWEs), and provide MCH services, treatment and diagnosis of common diseases, and simple laboratory tests. • Health posts emphasise preventive care (basic MCH/FP services, environmental health, first aid, and diagnosis and treatment of common diseases). Health posts are staffed primarily by FWEs, although some have nurses on staff. Each village with a population of 500–1,000 has a health post. • Mobile clinics reach remote populations on a monthly schedule, and are staffed by registered nurses or midwives. The mobile clinics provide limited primary health services (simple curative and basic MCH services). Health posts are open from 7:30AM to 4:30PM five days a week, while health clinics, primary hospitals, and district/referral facilities are open around the clock. Access to facilities and services varies and remains problematic in remote areas (such as the western, northern and northwestern parts of the country), though many facilities have been upgraded and new health units are being developed as an ongoing government project. Since 1996, there has been greater emphasis on increasing the number of health clinics and posts with trained nurses and midwives who provide basic maternal health services in communities (see Figure 3), and improving links to referral levels for emergency care. FIGURE 3 > NUMBER OF HEALTH FACILITIES BY TYPE (HEALTH STATISTICS REPORT 1997) 800 600 720 710 400 253 273 133 146 200 1996/1997 77 86 63 51 16 16 14 17 0 2000 District Hospital Primary Hospital Clinic with Maternity Clinic without Maternity Health Post with Nurse Health Post without Nurse Mobile Stops 6
Skilled Care During Childbirth: Country Profiles Botswana Drugs are provided under the rules of the Drugs Regulatory Committee, and are generally available, although some shortages exist, mainly in very remote areas. Equipment and supplies for basic maternal health services are also generally available (6) , though distribution and logistical problems do result in the frequent unavailability of such small yet necessary items as the angle poise lamp or blood pressure machines. Emerging programmes (i.e. the Programme for the Prevention of Mother-to-Child Transmission of HIV) have helped secure more and better equipment (i.e., silicon vacuum cups have replaced metal cups for vacuum extraction). Establishing Transport & Referral Systems A referral system links health posts with health clinics and hospitals. Protocols have been developed that allow a health provider to send a patient directly to a facility where specific services can be obtained (for example, in an emergency, a woman may be referred directly from a health post to a district hospital). For referral, most health facilities have a radio and receiver, at least one vehicle, and a telephone. In cases where the only vehicle is unavailable, paid transport from private sources will be arranged. Investing in Health Personnel Botswana has invested in improving the training and distribution of key cadres of health providers providing maternity services. Nurses and midwives form the backbone of the health care system and are the main providers of maternal health care. Most nurses provide routine antenatal and family planning services; those with midwifery skills provide the more complex family planning, antenatal, delivery, and postpartum care. Midwives trained in life-saving skills attend obstetric emergencies and co-manage obstetric medical/surgical complications with doctors. In addition to doctors, nurses, and midwives, FWEs play a role in providing maternal health services. They are primary school graduates who educate and motivate the community on issues related to safe motherhood—encouraging women to deliver in an institutional setting, and providing counselling and health education to communities living within a five kilometre radius of health posts. Training programmes: Over the last ten years, Botswana has improved and expanded training of health personnel providing midwifery care. In 1993, the National Task Force for Safe Motherhood commissioned a small expert group to review training for health providers. This group reviewed existing standards, protocols, and training manuals, and made the following improvements: • Pre-service midwifery training: The midwifery curriculum was increased to an 18-month programme with greater emphasis on antenatal care, labour, and delivery. It emphasised prevention and care strategies to improve maternal well-being. New content was added on the underlying causes of poor maternal health; safety and care during pregnancy, childbirth, and post-partum; and emergency care. • Since 1994, 562 midwives have gone through the training programme. Plans to increase the number of midwives to meet national targets and service requirements are underway. One obstacle to meeting this goal is the limited capacity of training institutions. Currently, there are only three midwifery training schools, as opposed to eight registered nurse training schools. Additional training sites for midwives are planned in the Southeast region of the country. • Other reproductive health training: Training for midwives in family planning has also been strengthened under the Botswana Population Sector Assistance Programme. Emphasis is placed on clinical skills and counselling, integration of STI/HIV/AIDS into family planning, and prevention, screening, and management of sexually transmitted infections. • In-service life-saving skills education: A six-week curriculum on high-risk pregnancies and life-saving skills has also been introduced for midwives and doctors. Skills include: procedures for completion 7
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SKILLED CARE DURING CHILDBIRTH - Family Care International

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