Examination of Witnesses (Questions 100
- 119)
TUESDAY 13 NOVEMBER 2007
DR TONY
FALCONER, DR
MONIR ISLAM
AND DR
NYNKE VAN
DEN BROEK
Q100 Sir Robert Smith: On the scale
of the human resources issue, in previous evidence we were told
about the need for 2.4 million health workers, including 700,000
midwives. Dr Songane emphasised that mid-level providers like
midwives, nurses and medical officers can be as effective as specialists
in providing emergency care. What aspects of emergency obstetric
care can be carried out by a specially trained nurse without requiring
a doctor's intervention?
Dr Falconer: It depends on the
level to which she is trained and how astute she is but if you
look at the real life threats in terms of eclampsia, in terms
of haemorrhage, there are first aid things that you can do and
I think that is in that evidence in terms of putting up magnesium
sulphate if you deal with an eclamptic patient. That is quite
within the roles of all midwives and, if you can, transferring
the patient to a safe place for confinement but again, if you
do not have that, just that intervention by itself will probably
save that patient's life until they deliver. Haemorrhage is a
more complex issue because massive haemorrhage requires supplementation,
or may require supplementation, with blood and that obviously
is not available. Doing a Caesarean section again is a variable
thing particularly in many of the African countries. The majority
of Caesarean sections are not performed by medical people at all
and the data is very encouraging. Also, it is much— can
I say this word here?— cheaper. There is good evidence.
Q101 Sir Robert Smith: The outcomes
are successful?
Dr Falconer: Yes. The quality
of the research is difficult to evaluate but certainly in pure
numbers it looks as though Caesarean sections done by medically
qualified doctors and those done by what they call, I think, clinical
officers, are very similar. In terms of what responsibility we
have this end, we still come back to base. We have a major training
issue responsibility and you have always got to have leaders.
You have to have people who can train people out there and essentially
you will never get away from that. There is a need for a core
of medically qualified people in any of these countries. Historically,
that was a responsibility enjoyed by this country. Sadly, at the
moment, the door has been slightly shut because International
Medical Graduates are not able to come to the United Kingdom.
That may open up again because the number of British graduates
has gone up so high, but in our discipline we still rely hugely
on people coming from overseas. What we need are structures so
that people can come temporarily to get the training access to
the qualities that we enjoy and then they have to go back. That
is the difference.
Dr van den Broek: Without a doubt
there are eight clear single functions of emergency or essential
obstetric care. All those eight functions— i.e., putting
up IV[6]
or anti-convulsants or oxytosis, the manner of removal of the
placenta, assisted delivery, vacuum aspiration for incomplete
miscarriage or abortion, Caesarean section and blood transfusion—
they can all be performed, the first seven, by nurse midwives
and are in practice performed by nurse midwives, if they are there.
Very often they are not necessarily legally covered to carry out
some of these skills and they have very little training in these
skills. Tony alluded to it earlier. There is a need to build the
capacity and the skills of this cadre of health staff, apart from
increasing the numbers, because I think I fully agree there are
insufficient, but to encourage them and to improve the quality
of care they are delivering. Caesarean sections: again, you do
not need an obstetrician or gynaecologist to do a Caesarean section.
You might want them occasionally to look at the quality and training
of doing a Caesarean section and worldwide of course most women
are not getting Caesarean sections in time and there are insufficient
people and resources to provide them. There is a huge human resource
issue there but skills upgrading is being discussed in many countries
and there are various models for doing this but I would say it
needs a lot more attention and close monitoring of what happens
if you improve people's skills, the effectiveness of delivering
the care, the quality of care and whether the numbers of people
coming to the institution for delivery and for emergency complications
go up because they know when they go there they will get good
quality, effective care.
Dr Islam: We also need to look
at all those initiatives that are good. We need to have human
resource planning. Sometimes the countries are deciding because
they want to do something "in the meantime", what they
need to do, but are not looking at the long term issues: their
legal issue, their employment issue, their retention issue, their
career issues. There are a lot of issues they need to look at.
Whenever the countries are thinking of creating a cadre for certain
work, we need to really look at all those issues and develop a
long term human resource plan. The countries need support for
this. Bangladesh now are giving training for community midwives.
It was decided by the previous government. Another government
might come and disrupt it completely, it has happened before.
There is an instance like that, so we also need to look at human
resource planning which is long term so that there are no disruptions
and you don't lose more money and time rather than gaining anything.
Q102 Hugh Bayley: Could I look at
the tier of health workers below that, the community based people,
traditional birth attendants? What should they usefully be doing
and how can their training be supplemented to ensure that they
provide high quality care? Do they need equipment kits?
Dr van den Broek: This is a big,
international debate which is probably why you are asking the
question as well. The current strategy— and there is good
evidence for that strategy— is that we need a skilled birth
attendant at the time of delivery because that is when most of
the maternal deaths and therefore the neonatal deaths occur. There
is international agreement about the definition of what is a skilled
birth attendant. It is a professionally trained person and then
you can agree to deal with at least the basic social care. The
traditional birth attendant— there are various names and
various cadres— is generally not able to provide that. Even
with a certain degree of training, they almost need a minimum
of 18 months' training and then they become a sort of public health
midwife like in Sri Lanka, as opposed to traditional birth attendants.
The role of the birth attendant is probably— many countries
are thinking about this both in Asia and, I believe, in sub-Saharan
Africa— more of one in the community to help with emergency
preparedness and to help so that the woman is able to prepare
for her delivery and then seek skilled birth attendants, most
usually at the facility. There is definitely a role for the TBA.[7]
Different countries have different strategies for what that should
be.
Dr Islam: I can give an experience
of mine working in a village health complex in Bangladesh. A woman
came after three days of labour with hand prolapsed. I examined
that woman. The vulva was swollen, smelling like anything. She
had a high temperature. The hand was hanging outside and the skin
came off of the hand of the baby because for three days they were
pulling the baby by the hand. That is what we are talking about:
delivery by mother and mother-in-law or TBAs. If we look at the
causes of maternal death, number one is the haemorrhage, what
would a TBA be able to do at home if somebody is bleeding? Next
one is the eclampsia which is a fit. What can a TBA do? The next
one is sepsis. Sepsis is happening. Pregnancy and childbirth is
a normal, physiological phenomenon. If you do not do anything,
80 % of the delivery will happen normally, but 20 % will need
some support, just to give you an example. Today, in many countries
where there are no skilled birth attendants or midwives, the complication
rate is 40 or 50 % because we are introducing complications because
we have no trained people. Untrained people are making our burden
higher. When you are talking about the normal delivery at home,
you need trained persons with many more skills. When deliveries
happen at the facility we have a lot of other people who can provide
additional support. But when you are delivering at home, even
in the UK when you are talking about home delivery, you need many
more trained persons, much more access to other accommodations,
transport and other things. The TBAs, according to all the metanalysis
done so far, really did not improve maternal health or maternal
mortality. They did not. What we are looking at is a collaboration
with the TBA? Yes. Investment? Maybe not. We should be investing
in the right strategy. In 1987 the same issue came up: TBA or
not TBA? Then there were forceful arguments: "skilled birth
attendants take time, in the meantime we need to do something"
and in the last 20 years we did not really invest in the right
strategy; we invested in TBAs. We need to look at the long term
issue. We need to invest in the right strategy. Yes, TBA can do
some collaboration, some support, psycho-social support and also
support of the baby, but delivery and childbirth is a complex
issue and particularly at home. It is a much more sophisticated
issue which cannot be done by TBAs.
Q103 Hugh Bayley: What proportion
of births in Bangladesh perhaps or in rural Africa are attended
by a skilled birth attendant?
Dr van den Broek: In sub-Saharan
Africa skilled birth attendance is between 40 and 60 %. Each country
has its own data. In Malawi, it is 45 %. I recently looked. Kenya
I think is slightly higher but within Kenya or within Malawi you
have non-equitable distribution so you might have areas where
it is very low, where there are very few—
Q104 Hugh Bayley: My prejudice would
say you are talking about urban Africa, are you not?
Dr van den Broek: No. That is
the average figure. In urban Africa it might be much higher.
Q105 Hugh Bayley: Exactly. That is
what I am saying. If it is 40 % coverage, then most children in
urban areas would have a skilled birth attendant and few mothers
in rural areas would have.
Dr van den Broek: In urban areas
it is more than 50 % generally, yes. Bangladesh I do not know
about.
Dr Islam: I think you are pointing
in the right direction. We need to look at the urban area. In
most of the countries, the rich people will reach MDGs, not the
poor people. Why should we be providing poor options for poor
people and all the higher options for rich people? The politicians
in the country need to decide the right strategy. Every woman
should have the right to the best care during pregnancy and childbirth
and the best care would be a skilled birth attendant and access
to emergency obstetric health care. What are we trying to say?
The government and the politicians have to take the decision.
Yes, it will take time but the decision has to be made today.
Q106 Ann McKechin: Can I follow on
with the issue of geographical spread of medical experts and the
problem of trying to incentivise the doctors and skilled employees
to work in rural areas? I wonder if you could give me some indication
of what actions you think have worked in trying to incentivise
that? What are the key components? Is it issues of salary? I think
you mentioned, Dr Islam, that also there would be an issue of
the general conditions in which people are living and also the
back-up they receive. I just wonder whether or not you can point
to any good examples which you think DFID should be supporting.
Dr van den Broek: Generally health
care providers the world over are the same. If you can provide
them with good housing— in many countries, the government
provides an increased housing allowance if you live in a rural
area or the government builds houses in rural areas— then
it becomes more attractive. Also, nearby education or extra salary
to deal with having to send your children further away for education,
for example. There is a number of incentives that can be used.
I would have to ask our human resource expert. I have not recently
read the report on which countries have the best and the most
successful initiatives. I only know anecdotal evidence from the
various countries. The one we most recently discussed is the one
in South Africa where young doctors are made to work in district
hospitals. I was talking to one of my colleagues from South Africa
in the last month and that sounds like a very good idea. I always
thought it was a good idea, but if the working conditions are
not adequate, if the supervision is not adequate, they actually
find it very difficult to function to the extent that they would
like to function, just having come out of medical school. They
become very demoralised and I understand there is quite a high
suicide rate and depression amongst these people. Again, there
is not a very straightforward solution. In north Nigeria, where
we visited, it was quite clear that doctors said, "We need
extra salary if we are to work out in that particular state because
it is two hours away" and a certain amount of commuting was
being done which was making it difficult to ensure 24/7 coverage
with maternal health services. That seemed to be an incentive
that was working relatively well, so different strategies I think.
Dr Islam: I go back again to 1979
when I had finished my medical education and I was posted to a
village health complex. I went and I joined at the complex but
some of my friends, because they had higher connections, managed
to change their assignments. Why am I saying this? Because this
is a question of good governance. If the doctors know that they
will be in a village complex for a certain period and will not
be rotting there for a long, long time they will go there. So
it is not only the salary; it is other incentives. If you go and
work, you have to work in a village three years or four years
after graduation. If you do that you have access to higher education.
You will be able to apply your higher education. That would be
an incentive. Talking about accommodation and other things, that
is also an issue. In India, in Himalchal Pradesh, where in the
winter there is snow, nobody can go out. What the Chief Minister
decided was that any doctors going there, working in the winter
season, would get one year's salary more as an incentive. Their
children will have the education facilities. There are a lot of
other incentives you can provide. Salary increases will not be
easy to provide because there is a public service issue. But there
are other ways of providing the incentives. Mostly, we need to
have a fair system so that individual doctors and nurses understand
that even if they have a protest they will have it fairly because
everybody is doing their duties. But it is not really happening
because of an absence good governance.
Dr Falconer: The brain drain is
what you are alluding to. If you talk to doctors in the United
Kingdom on whom our health service has relied, as you know, 40
% of the infrastructure is made up by people who trained overseas.
If you look at countries like Mozambique, I think Mozambique has
750 doctors now in the whole country. My hospital in Plymouth
I think has more doctors than the whole of Mozambique, just to
put it in perspective. If you ask these doctors from overseas,
"Why do you come to the United Kingdom?" you can imagine.
You get free health care. You get good schooling. You have political
stability and you can externalise money back to your roots. Many
of these doctors are externalising large amounts of their salary,
so they are far more effective in terms of their infrastructure
responsibilities and they are different to us. I have to be very
careful in what I am about to say because I think many people
have gone into medicine for totally altruistic reasons or certainly
they used to, and now it is a business for many of these people.
Q107 Ann McKechin: I think that is
a distinction. Perhaps in some countries you mentioned there was
compulsion. In somewhere like China, Nicaragua or the Communist
regimes, people were compulsorily sent out or in the past people
went out based on religious motivations. It seems it is trying
to get the right mix of finance and other support.
Dr Falconer: I am slightly naïve
on this and what DFID can and cannot achieve but whether you can
develop contracts for certain of these countries overseas to say,
"Yes, we will take you for a short time, a two year block.
We will train you and you can acquire these quality standards
that you want to take back" and they have to go back. There
are models for that sponsorship scheme but it may be that that
should be developed further and you could top slice a certain
number of training opportunities in the United Kingdom and, say,
fill those with people from the countries that we want to develop
and then send them back.
Dr van den Broek: I also wonder
whether personally I can add to that, having visited most of these
countries. I realise that we in positions of leadership and maybe
power do not pay enough attention to these rural areas. It is
much more difficult to get there, to go and see what is happening.
I am not sure that these people always feel valued or part of
the system and that is partly to do with us and how important
we make services in the periphery. It is very easy to concentrate
on the urban assessment, the urban needs and so on.
Chairman: We saw evidence of that when
we were in Malawi. We visited a rural hospital which was desperately
poorly staffed and equipped with a huge number of patients and
you could see that.
Q108 John Battle: You have opened
up the whole question of the global economics of it. It is interesting
that you helpfully open it by raising the question: is health
care a business because, if private hospitals or care homes in
Britain are recruiting nurses, I met a midwife in a care home
looking after older people precisely because she could send more
money home as remittances to her village. She believed that was
doing more good than working in her village as a health care midwife.
We have heard in a previous session about— I think it was
2.4 million overall total shortage of health workers, absolute
shortage, and included in that figure are 700,000 midwives. I
just wondered where the debate would go in terms of: you cannot
just have a fair system in one country, can you? Global economics,
whether it is telephones or whatever, as the jobs fill around
the world, what more could we do perhaps to encourage not just
sponsorship but exchanges? Do you think in the wider world of
medical care that, if I dare said the ethics of exchange or the
idealism of it, is still there and would work where trained people
here also went there and vice versa— could that be opened
up in a new way?
Dr Falconer: Nynke is the expert
on ethics. I am not good on ethics but I will talk about the exchanges
a little bit because historically that was the very pattern that
used to happen. I am an example. I worked in Zambia and in South
Africa. Very many did. That model needs to be developed. If the
opportunities can come for people to come to the United Kingdom,
many of our trainees' whole lives would be transformed by working
in the developing world. You ask which countries do we have an
association with? I am just talking now of the RCOG. All our roots
are with the old Commonwealth, rightly or wrongly. They are beginning
to change a tiny bit but if you look at India we have a massive
presence of people there. If you look in South Africa, we have
a big presence there. In east Africa we have a much smaller presence
but those are the countries, so inevitably, because we have little
infrastructures there, that is where we would look to.
Dr van den Broek: I did not know
I was an expert on ethics, but we are very concerned about this
issue of brain drain. I am not a global economist but I did some
Economics at O level. I thought if you had enough nurse midwives
the world over then you would not have this issue of us having
to poach and America having to poach. We really must put more
emphasis on training a higher total number of people. Yes, there
need to be incentives for them to stay, maybe bonding, quick employment,
proper salary, proper status, but I suppose legally and ethically
you cannot stop people moving around. Perhaps we do not want to
stop people moving around but the bottom line, as I understand
it, is there are insufficient health care providers, particularly
midwives. Maybe we should strive for that primarily.
Dr Islam: There were some interesting
discussions in 2005 on brain draining where all the ministers
were there and discussing the issue. Some countries from Africa
were asking for compensation but the Philippines were saying,
"No, do not stop our brain drain because that is our foreign
currency". So we cannot stop people moving and everybody
has the right to move around. There is no one solution to this
issue. What I was talking about in Zimbabwe— the training
issue. Can we think about improving the faculty and training schools
so that they can have enough people trained there which they can
have and also fulfil the demand of in the USA, the UK and everywhere
where there is high demand for this cadre of people. In the UK
or the USA nobody is very willing to go for midwifery and other
training. If you have freedom of movement, you will not be able
to say you cannot move, so we need to look at where is the best
way. The country really needs more investment on training at the
country level and good quality training.
Dr van den Broek: There is good
evidence coming out of Malawi, where DFID has said, together with
other donors, that there are ways to improve training in country
by exchanges of tutors but also strengthening our midwifery schools
and all cadres of staff in addition to supplementing of incomes
which you will know has been done in Malawi. I was just reading
that report. It is available to read. It discusses the issue of
the whole structure and support of human resources once they are
trained, so they need to be available to be trained. There needs
to be a minimum of education so you can have the right quality
people to go into training. Once they are trained they need to
be immediately deployed, not having to wait for two years for
a contract from the Ministry of Health. They need to have in-service
training. There is a whole model by which this can be implemented,
which I understand has been evaluated as part of the general evaluation
of sector wide approach in Malawi by DFID.
Q109 John Bercow: You mention Malawi
and of course the Malawi Emergency Human Resources Programme running
over a period of six years is one means by which DFID is seeking
to address the problem of low human resources capacity and brain
drain. You refer to improving the rate in Malawi and that prompts
the question— or at least you give the impression of being
open minded about it— what evidence exists to support the
use of emergency schemes of this kind and what dangers, if any,
do they carry?
Dr van den Broek: We have talked
to the human resource experts, because this is not really my particular
area of expertise. I understand that the jury is still out whether
the £52 million from DFID and then another £50 or so
million from the Global Fund, over a period that I think started
in 2004 and is meant to go on to 2010, has had an effect. The
bottom line is it is quite difficult apparently to monitor what
happens to such monies, a 52 % increase in 11 cadres of staff
in health provision as opposed to the rest of the public health
sector, because of the way the monies were administered. They
were either part of basic salary or part of allowances. I understand
it is easier to monitor if they are part of allowances. There
is a desperate need, now that this has happened in Malawi—
I think it was meant to be a test case— still to commission
a separate report just to look at that issue, to come up with
lessons learned because the jury is out and the answer is not
that simple. It seems to have done some good and some not so good.
Q110 John Bercow: It raises the associated
question of whether, even if there is a benefit from such a targeted
initiative, there might not also be a displacement effect. This
of course is very much a feature of the political system in a
great many countries. It is a feature of democratic policy in
a sense that the people who lose out might well be disparate and
in a number of different locations and not even be aware of the
fact of their losing out and therefore disinclined or unable to
protest about the fact that they have lost out; whereas the beneficiaries
of the targeted intervention are likely to say, "Three cheers".
Dr van den Broek: That is true.
Two of the immediate criticisms, if you like, of the way it was
handled in Malawi: one, it was not immediately transparent to
all the cadres of health care workers how and when this was going
to happen; two, it would seem— but you should really get
a proper report from the human resource people evaluating it—
that the people at the top got 800 % on places and the people
at the bottom got 150 or something. Please do not quote me on
the figures. It is not that simple to just pour £52 million
into a government and say, "Go ahead" along with other
things like finance. There is this huge issue as to the capacity
of ministries to monitor a huge amount of money and there is insufficient
accounting probably.
Chairman: We had one anecdote from a
nurse in Malawi who said that she got a 52 % uplift in her salary
which was quite helpful but, on the other hand, the government
had made education free and the standards had fallen so low that
she was now having to pay school fees which were more than the
pay increase, which I think is John's point about unintended consequences
and their subsequent effects.
Q111 Hugh Bayley: First of all, on
Dr van den Broek's comment about training in relation to the brain
drain, I am all for improving the volume of the numbers of people
training in developing countries but surely, if you really want
to deal with the brain drain, you should be substantially increasing
the number of doctors, nurses and sub-degree level nurses who
train in this country. Leaving aside the intellectual exchange
in training issues, which we want to retain, the immigration rules
say you can only appoint a Philippino nurse if you cannot find
a British nurse.
Dr van den Broek: I absolutely
agree. There need to be enough midwives worldwide to look after
women who are pregnant and need to deliver.
Q112 Hugh Bayley: Maybe one of our
recommendations should be that UK training of health personnel
should be a manpower/person power plan that affects our training?
Dr van den Broek: Yes. Maybe use
that experience. Also, maternal deaths are happening in resource
poor countries on the whole. I agree entirely but can we use that
experience then to also help resource poor countries improve their
training and their numbers so that we are sharing.
Dr Falconer: The only plea I would
make is that we are British personalities and we should be leaders
in many aspects of health care, as we are in many other things.
If you are going to influence countries, you have to maintain
an opportunity for those people to come over and work and be influenced
by us, whether they are midwives, nurses, doctors or whatever.
I support entirely your philosophy. If, as it should be, you provide
for our own needs within the United Kingdom, you have no need
for external people. We still need to maintain a two way dialogue
and flow. One of the dangers of where we are currently going that
I am a bit scared about is that that two way dialogue may stop
because we just have to protect our own people, and literally
I do mean protection because you may have medical unemployment
for the first time ever in the United Kingdom in the very near
future. I maybe wrong.
Ann McKechin: That would encourage them
to go elsewhere.
Q113 Hugh Bayley: I agree in principle
although I do know that, even if you take somebody for a one or
two year training programme with the expectation that they will
go back, they may well find they are better trained and more marketable
in some third country rather than going back.
Dr Falconer: I accept that. I
am talking institutionally now. The advantage that we have is
that, when they go back, they are always part of our organisation
and the quality standards— we have not talked about this
at all today— that we produce are not just applicable to
British women. They are applicable internationally and when you
travel overseas and you talk to doctors who are members of our
institution what is the one thing they really like? It is that
they can go on a computer if they have access to it and get the
clinical standards. We talked a little bit about eclampsia earlier.
We have very good guidelines and those can be translated everywhere.
Q114 Hugh Bayley: Why is it so important
to have good statistical data on maternal deaths? You have said
in your evidence it would be good to adopt a look alike to the
UK confidential inquiries approach. What would that look alike
look like stripped down to its bare essentials in a developing
country and why is that different from what is available now?
Dr Falconer: 1952 was the first
production of the confidential inquiry into maternal death. That
is still today used as the hallmark in many countries of the world
as the paragon of audit. That does not answer your question specifically
to overseas but that is what it starts from.
Dr van den Broek: Your first question
is why statistics, because I have heard numbers talk probably
more than not having numbers. It is very difficult to collect
maternal health or maternal death numbers, as you have heard already.
In some ways it might be a better effort to look at why mothers
are what these audits are all about. There is good evidence especially
from South Africa where they have really started on a very good
national confidential inquiry system. From that they have identified
exactly what the problems are and have used that to focus intervention
and focus budgets to address those issues that are still not in
place, which is why mothers die. Sri Lanka has also a very good
maternal death audit system but it is in the field, so there is
a self-evaluation of every maternal death by health care staff
involved or community staff. At the district level, that brings
up all the issues that need to be addressed to stop this, hopefully,
happening next time. The problem in Sri Lanka is they have not
reached the national level and they are not producing beautiful
reports, but they are doing it. Then there are countries like
Tunisia, if you like, where everything is there but birth registration,
death registration. The private facilities are somehow outside
of the system but the majority is there. Again, if they had a
little bit more effort and understood the importance of this,
they could produce these statistics almost or at least why are
these women dying in our countries still. That would help to address
the problem.
Dr Islam: We have issues if you
look globally. Only 35 or 40 % of countries have got death and
birth registration and causes of death reporting, so the other
people are not reporting. I always like to give an example. When
I was getting married in Holland, they wanted my date of birth
registration certificate and I gave my school certificate. That
was my date of birth certificate. They said, "No, we want
something from your birth registration in Bangladesh", so
I had to call my mother. "Can you please give me my date
of birth registration?" Then the person in the register called
me. "Can you tell me when is your date of birth?" so
I had to tell her what was in my school certificate. There was
no registration. That is the situation we are talking about. Why
statistics really? It is necessary. A demographic and health survey
has been carried out in 78 countries and they publish very good
documents. It is being used at a national level but what we are
doing now is some secondary analysis of those data like in Zimbabwe,
like in Zambia, like in Chad. What we are doing now is to see
the difference between urban and rural births, access to skilled
birth attendants, Caesarean section and other things. What is
the difference between different districts? Are all the districts
performing the same or not? What is the difference between rich
and poor? If we do the secondary analysis, then we can say where
we really need to put our attention. That is where the statistics
are necessary to really plan where we should be putting more emphasis.
Is it universal coverage for everybody or do urban slum areas
we need more attention or do rural areas we need more attention?
The data will provide you with that and the data also provide
you with support for advocacy purpose at the national level and
at the global level.
Q115 Hugh Bayley: Who should take
the lead— should it be the World Health Organisation—
to ensure that a reasonably competent minimum set of data is collected
in each country? You have cited a couple of examples, Sri Lanka
and South Africa. Rather than British donors using the Royal College's
model in a few hospitals where they work and a different system
being used in a different region, somebody has to look at it strategically,
have they not? Which should be the agency that leads this globally?
Dr Islam: There is a global initiative
which has been supported by different donors and also by DFID,
the Health Metrics Network. The Network is looking at how they
can improve the statistical data collection and analysis that
are used at the national level. The Network is housed in the WHO.
The partnership for maternal and child health is also housed in
the WHO. We realise the monitoring system is not really working.
That is why we are trying to improve that system at the country
level. From our side and from our department, we are trying to
develop the country level, as well as the district level, monitoring
and evaluation system.
Q116 Chairman: There is just one
final issue, thinking of our own experiences in the countries
we visit. Rural areas are very rural. The roads are very rough
so many, many people are living not only a long way from any existing
infrastructure but one suspects quite a long way from any potential
infrastructure. The question you have is: in reality, is the only
option for those people that they have skilled birth attendants
in their community and an expectation of home births and possibly
some process of identifying risks that you can identify prior
to delivery but not obviously being able to transfer at the point
of delivery very far. What is the priority? Is it to get women
to be where they can actually get full clinical intervention or
is it to try and give them the best you can in home delivery circumstances,
knowing that that is still going to leave some of them at a risk
that is not able to be addressed?
Dr van den Broek: It is an interesting
point that is put to us quite often. Where we have done surveys
of districts or regions to see what facilities are there, generally
there are quite a large number of facilities, structures, some
degree of staff, but none of them are fully functioning. Often,
there are a lot of different facilities; none is properly functioning.
It needs to be rationalised in line with at least a minimum agreed
by the UN bodies of full basic emergency obstetric care and one
comprehensive for half a million people. That can be done, maybe
not with the minimum, but it is a focused approach. That can be
mapped out and carried out, together with making sure that women
of course can access these facilities because, yes, there are
issues of roads. There are very imaginative ways of dealing with
emergency transport, motor cycle ambulances, stretchers. My experience
is mainly in sub-Saharan Africa so areas like Afghanistan and
the mountains of Nepal are a different case, yes, but in sub-Saharan
Africa where a lot of maternal deaths are happening there are
good examples of combining equitable distribution of especially
the basic facilities, where at least the basics can be done by
the nurse midwife and then transfer to a hospital which might
take a little bit longer, plus transporting the patient.
Q117 Chairman: You are implying it
would be a big mistake to try and trade one against the other.
You really have to try and make sure they are both pursued together?
Dr van den Broek: I think so and
that has been the struggle because people always want to hear
it is this one, single thing.
Q118 Chairman: No. We want to know
what you think.
Dr van den Broek: Our experience
tells us that that is what we have to aim for.
Dr Islam: If you look at Africa
where most women, 80 % or more, will come for antenatal care one
time, two times or three times, walking all the way, but they
do not come for delivery. Why? Because the quality of care they
receive at the facility is abysmal. Sometimes supplies are not
there. If you have seen that film on Panorama, Dead
Mums Don't Cry, drugs and supplies are not there, so the woman
does not want to come. The options we are giving women are either
you die at home or you die at the facility, so they decide to
die around their family. That is the issue we need to look at,
the quality of care. The other issue is what Nynke said, a different
type of transport. What we have done before is build a maternity
waiting room, to have a facility near the main facility where
women can come one month or 15 days before and they rest and do
some type of work and, when due, they go to the main facility
to deliver. There are different ways of looking at it. There is
no single way we can reduce maternal mortality. If our goal is
to reduce maternal mortality there is no other way but to provide
skilled care and emergency obstetric care.
Q119 Sir Robert Smith: How quickly,
once you provide the skill, would the message get back to communities
that they can now trust the services provided?
Dr van den Broek: Very quickly.
A month, I would say, but it is true that enough care and enough
quality care.
Dr Islam: If you look at Botswana,
that got independence in the 1960s, at that time Botswana had
a low percentage of delivery by skilled birth attendants or at
the facility. Today, 98 %. If you look at the local tradition,
they managed to change because they are providing reliable, quality
care. That is why women are coming there. It was nice to work
for ten years in Botswana because of the quality of care they
are providing, so it is possible.
Chairman: Thank you. That is extremely
helpful to our inquiry. You have really taken us through those
issues with a great degree of clarity as well as your own expertise
both as professionals but also with real experience in dealing
with the countries that we are most concerned about. I really
want to thank all three of you very much indeed. It has been a
really helpful session.
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