Challenge of poor transport for emergency referral systems
Rebecca (pseudonym) is a 30-year-old woman from Gamborungu in the Bongo District of the Upper East region. Rebecca is pregnant with twins at 36 weeks; her fourth childbirth.
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She received assistance in preparing her home for the arrival of her newborns (by her mother-in-law).
As with her previous pregnancies, the local Traditional Birth Attendant (TBA) reminded her of the need for a nutritious diet, encouraged her to have a facility birth and influenced her family to remain supportive of this.
Rebecca went into early labour at 3 p.m. in early July. This was during the planting season and since Rebecca was needed in the fields and her pains were not severe, she joined in the farming activities.
She spent the entire day working in the fields and did not reach the TBA’s home compound until dark. By 9 p.m. they decided to make their way to the Health Centre because the contractions were more severe, although tolerable. Because the family had no means of transportation, they asked a relative to carry her on his bicycle while the TBA walked alongside. The health centre was a two-hour walk away.
An hour into the trip, heavy rains commenced, flooding the dirt road. Forty five minutes later, the labour contractions became more rapid and severe. Rebecca became too uncomfortable to balance on the bicycle, so she begged to be let down.
Upon being let off the bicycle, she leaned against a large rock where she proceeded to push the first baby out into the streams flowing down the muddy road.
Next, she pushed out the second baby, still leaning against the rock for support. Startled and shaken at the sight of the blood, the male relative fled behind the rocks. The TBA struggled to pull out a pair of sterile, but no wet gloves to cut the cords of the babies. The placenta delivered suddenly with an excessive amount of blood.
Stillborn
The TBA kept her attention on Rebecca trying to massage the uterus, vigorously attempting to avert a postpartum haemorrhage. As the bleeding was eventually controlled, the TBA looked over towards the two babies but could not see them in the dark. However, the crying of the girl reassured her. When she found the boy, he was limp and silent, although not cold. She attempted to stimulate him by rubbing his skin, but he could not be aroused so she pronounced him a “stillborn.” She wrapped the girl in a cloth and attached her to the mother’s back and also wrapped the boy and carried him. Rebecca was then assisted by the male relative onto the bicycle. Their journey to the health centre took 15 minutes. Upon arrival, she was found to be severely anaemic and was immediately sent to the district hospital in Bongo where she received treatment and was later discharged.
This incident took place in 2010, a year before a Community-based Health Planning and Services (CHPS) compound was built in Rebecca’s local area, and three years before the compound became part of the Sustainable Emergency Referral Care (SERC) project initiated under the Ghana Essential Health Intervention Programme (GEHIP) by the Regional Health Directorate.
Ambulance
If Rebecca was to have her babies today, she would have been able to call an emergency number to be picked up by a SERC Motor-king “ambulance.” She would have been in early labour at the CHPS compound and would have been seen immediately.
She would have been referred and transported to the Zorko Health Centre by the Motor-king and would have arrived just in time to have a facility birth by a trained midwife.
The baby boy would have been suctioned and possibly revived by a midwife who had received neonatal resuscitation training. She would have received the appropriate treatment as soon as bleeding (postpartum haemorrhage) was suspected. She and the baby girl would not have been sent alone to the district hospital in Bongo to receive blood transfusion. She would have arrived home two days later with not one but two healthy babies.
In an emergency, every second counts. The lack of transport can cause significant delays to a patient receiving treatment. The cost of poor emergency health referral systems in Ghana, particularly rural and remote communities and other parts of the world, is massive.
It is widely considered that more than half of pregnancy related deaths that occur in developing countries could be averted if appropriate emergency referral facilities were readily available, affordable and accessible, particularly in rural areas.
This is a major challenge we need to address in saving women. We have no option than to address the serious challenges of poor transport for emergency referral in our healthcare delivery system.
The writer is Upper East Regional Director of Health Services
Email: [email protected]
