Evaluating what we do

How effective have our efforts been? In December 2009 we asked a French midwife, Nelly Staderini, who was based in Chad, to carry out a  formal evaluation on our behalf.  Below is a summary of her findings. Since 2009, a number of her recommendations have been enacted. 

Midwives at work

Midwives at work (photo: Nelly Staderini 2010)

Nelly, a French midwife previously based in Chad, has taken an active role in SBICF. She offered to travel from her present home in Burundi in December 2009, to carry out a week-long evaluation of the impact of SBICF activities over the past 3 years. We agreed to pay her air fare. Her evaluation was thorough and covered every aspect, with mornings spent in the maternity units with midwives and doctors, and afternoons in meetings with the Health Ministry, hospital managers, midwifery trainers, the Midwives’ Association, the UNFPA, the EU officials, the bio-technician, and the new head of maternity at the National Reference Hospital.

 

Here are some of the main points, and recommendations, about the situation on the ground in the maternities.

Logistics

The water system works very well at Farcha, but Chagoua is still using buckets. Portable Solar lights no longer working, lighting remains a serious problem. Toilets need renovating, & latrines needed at Chagoua. 
Recommend: Improve water at Chagoua, renovate toilets, install latrines. Install solar lighting systems. 2013 - Chagoua finally has reliable running water throughout the hospital, in a partnership – SBIC paid for plumbing improvements, the Hospital pays to keep the small generator going for the pump. Toilets renovated in 2011. Latrines put up by OXFAM.

Supplies

Some of the equipment donated (e.g. B.P. machines, pinnards) are used but not consistently. Birthing kits very useful but supplies have run out. Constant need for gloves, wipes. No oxytocin available in the hospital pharmacies – patients must buy locally if needed
Recommend: Increase supply of birthing kits X2. Misoprostol ( haemorrhage treatment) and Haztabs ( for hygiene) to be included on Central Pharmacy list as part of SBICF renewed agreement (see below re Mag. sulphate).  2013 – Birthing kit supplies improved by faster delivery system. Oxytocin generally available and used in delivery of babies to prevent hemorrhage.

Changes in practice following SBIC training visits

  • Standards of hygiene are generally much improved inside the buildings
  • Trainers & midwives disagree about whether or not midwifery trainers are in the delivery rooms to supervise students. Some students from private training schools are left unsupervised. State trainers do supervise students in hospitals. 
  • All but one of the midwives have been trained in treatment of eclampsia using mag. sulphate and know how to use it. Mag. sulphate supplied by SBICF nearing expiry date (but see below)
  • Students still seem poorly motivated & not managed
    Recommend: Next visit should focus on a better system for supervision of students by the trainers & midwives. 2013 – some hospitals have better supervision of students than others.

The Chadian midwives are well aware of “best practice” in theory, but still on the whole do not put this knowledge into practice. Some of the changes strongly recommended by the British trainers are beginning to be enacted, such as abdominal examination of women in labour, but there is no change in behaviour towards women in labour – little empathy or kindness shown. But, treatment of newborns is much improved, along the lines suggested by our trainers. A priority is for midwives and doctors to improve the way they behave towards women in childbirth. Unfortunately, hospital birth is often an unnecessarily bad experience for women and this constitutes a real barrier to access to the care women need. 2013 – treatment of women highlighted as a priority by trainers. Awareness growing among midwives of the need to give respect and kindness. 

Recommend: Have “good practice” guidelines displayed – (methods & approaches not involving drugs or equipment) – and work with the heads of maternities to evaluate midwives’ application of these. Only give further training to those who consistently apply basic good practice.

Record-keeping

Births and nos. of women referred to the HGRN are recorded, but much useful info. is missing – no collection of data on problems encountered. Partograms are used consistently at Farcha but not at Chagoua – management has ignored head midwives’ request that these be supplied. (Available free from W.H.O.)

2013 – standard WHO records used for each woman, in all hospitals -reasons for referral or problems noted. Some follow-up of women referred . 

Health Ministry undertakings in agreement with SBICF

  • Magnesium sulphate was added to the Central Pharmacy list of essential drugs to be imported, in November 2010…. .2013 supply remains inconsistent
  • An obstetrician, Dr. Dangar, has been appointed as Dr. in charge at Chagoua, but has so far not begun work. 2013 Dr. Nehemey appointed as MCH, has begun to carry out  caesarian operations. 

Recommend: Improve the referral system with data collection on reasons and outcomes for referred women. Request that Dr. Dangar takes up his post.

  •  In 2012 a new build reference hospital with improved facilities,, “Mother and baby” (“HOME”)was opened. Chagoua and Farcha hospitals have ambulances operating 24 hours.

Local leadership

The Chadian Midwifery Association now has over 60 members – half the total midwives in Chad. The Chadian midwifery trainers play a leading role. They are keen on a partnership with SBICF.

Recommend: The next visit should strengthen ties between British midwives and the Chad Midwives Association. SBICF can help them develop their programme of activities. They could take a leading role in establishing standards for midwifery. Training for the TBAs [Traditional Birthing Assistants] who currently deliver the vast majority of Chad’s babies, could be a significant project for future funding by SBICF and other sources (EU?).

Chad Midwives Association now numbers 70+ members & has an office funded by UNFPA.

Maternal mortality statistics from the HGRN [the National Reference Hospital]

Many women in N’djamena who develop complications in childbirth, whether at home or in the district hospitals, end up in the HGRN. This hospital has a very odd way of compiling statistics on maternal mortality. It would seem that women who die within 12 hours of admission are counted, and also women who die more than 48 hours after, but those who die between 12 and 36 hours…..appear not to be included. If this is indeed the case, there would seem to be a significant under-reporting of deaths. There were no deaths of mothers in either Chagoua or Farcha( but it is likely that some of those referred, died).

2013 – no statistics seen from HOME for women referred.

Recommend: Hold a teach-in on referral at the HGRN (including staff from the 2 district hosp’s). HGRN director agrees with this. Hold a training in recording deaths & analyse the statistics, with HGRN midwives, doctors and manager.

Finance

EU could be approached for funding for a joint proposal with ENASS (Chad midwifery & nursing school) to improve the training of midwives.

2011 -2012 Joint proposal put forward to appropriate fund by the head of the ENASS – training school for Nursing & Midwifery, with role for SBIC as overseas expertise, but no funds forthcoming.

 

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