The SBIC story 2005 -2011

‘Dead Mothers Don’t Cry’ – an overview of SBIC’s work from 2005 – 2011 by Ann Pettitt, Chair of SBIC.

On 26th. June ( 2010) it was  five years since BBC’s Panorama programme showed a documentary about mothers dying in childbirth in the central African country of Chad (Dead Mothers Don’t Cry). The film highlighted the struggle of a conscientious obstetrician, Dr. Grace Kodindo, to care for mothers and infants in the face of appalling conditions, lack of basic life-saving drugs, and an indifferent health ministry. Five years is a good time to look back and think, “What difference have we made? And, “What have we learnt?”

We got a group together, we visited, and found that things were not quite as simple as they seemed in the film. Grace had left her job of thirty years, as head of the National Reference Hospitals’ maternity. She knew the hospital continued to lack many basic essentials for a reference hospital dealing with women who developed complications in childbirth, and had agreed to the BBC film as an opportunity to bring about improvements, by highlighting some of the problems faced by doctors and nurses.

Were we naïve, misguided, vain even, to think that we could make any difference? Naïve we were certainly –“We can give, they can’t receive” was the surprising statement by Vincent Fauveau, head of the UNFPA Maternal Mortality section, when we met during that first visit in 2005. It was the first of many times when I would feel brought up short. Naïve we were to think that the “oil money” now flowing into Chad would make any difference. We misguidedly assumed that the problem was mainly a shortage of drugs and equipment, whereas women often die, even when they reach a hospital, for more banal reasons of negligence, incompetence and poor administration.

We followed our hearts, and obeyed a basic human impulse, to seek to help others, and I think we were right to do so. Millions have been spent by large, well-funded organisations on maternal mortality in Africa in the past 20 years. Pledges have been made, resolutions passed, conferences held. Yet, in the countries with the highest rates of death, none of this has made a  significant difference. Maternal mortality remains as high as ever.

Two district hospital maternity units – Chagoua and Farcha

It was towards the maternity units of the two district hospitals of the capital, N’djamena, that Grace suggested we direct our energies and goodwill. She knew they were more desperately under-resourced than the National Reference Hospital, and that we could make a real difference to them. One hospital, Chagoua, is close to the crowded African city “quartiers”. It is always overcrowded, with patients being treated in makeshift tents in the yard. The maternity unit, with four beds, seems flat out with women sometimes delivering on the concrete floor, and others in labour on the benches outside, waiting for a bed. The “beds” are ancient rusty things covered in torn black rubber. The state-run electricity supply doesn’t work at night so they use candles or paraffin lamps. The state water supply is so unreliable that they use a borehole well, but the electric pump stopped working, so the midwives had to carry buckets of water to fill up the barrels inside the delivery room, to keep the floor, walls and beds washed down.

The other hospital, in the district of Farcha , is on the edge of the city. Women arriving to have their babies at Farcha have often walked many kilometres from their village. I remember being there in 2009 when a young-looking woman had walked 20 k. from her village with her family. She was in labour with her 11th. baby. She did not know her own age. Another knew her age – sixteen – but had no idea why her tummy had got so big, nor why she was now in such pain. She thought she must be terribly ill.

A year before that, I stood with Paulette Lewis , midwifery administrator in the UK, President of the Nurses’ Association of Jamaica, UK, on her first visit to Africa, in the delivery room of Farcha hospital. The walls were grey, greasy and splattered with dried blood. A bed had a pool of dried blood beneath it. Instruments are “sterilized” by leaving them in a kidney bowl of bleach solution. Paulette took one look around her and said to everyone standing in there – “This is FILTHY! We are going to CLEAN IT UP!” And so we all did – the “Head of Midwifery “ ( a man who, it should be noted, had tolerated rats in the delivery room cupboard) the caretaker, the midwives, the students, Paulette and myself. “Madam” said the Head of Midwifery at one point, “Put down your mop. I should be doing this, not you”. “You are quite right” I said, and sat down.

Have we learnt anything?

That little story is about what we have, I hope, learnt – that it’s really irrelevant for us to be shocked and to see the need for change. Unless people in Chad want to tackle their high maternal mortality; unless the people in charge want to bother to clean the delivery rooms for which they are responsible (and to which women come in the hope that they will be safer); unless the midwives want to make sure that no woman they have delivered goes home to die of a haemorrhage, or develop an infection they have given her from dirty instruments – unless they know that negligence will be noticed – then we can give equipment, drugs, even training and nothing will change.

It’s the management, stupid

When we blithely undertook to pay for generators as part of our agreement with the Chad Health Ministry (without which we would not be able to visit or work with hospital staff), we did not consider to ask why the previous generators had stopped working. I asked the people in charge of a big bucket of money, the EU aid-for-Africa programme, why they could not pay for generators to provide lighting at night in these places. “Because of the management” they said. “It would be a waste of money, so long as the management remains as it is. If the state won’t pay for any maintenance, things will break down”.

Another lesson: it’s management, admin, accountability, responsibility – lack of, that underlie so many of the apparent failures we have seen. Another little vignette: a whole team of people, including us and even our taxi-driver, is cleaning and repainting the delivery room and midwives’office at Farcha, in 40 C heat. The hospital manager, a large, affable man, is sitting under a tree in the shade. Used needles and faeces litter the grounds.

He has since been replaced.

“It’s not easy to ‘help” – Nelly Staderini, French midwife, public health specialist, wife of former Head of MSF Mission in Chad, closely involved with SBCF since 2006.

Did we start by asking the wrong questions? “What do you need?” We asked, and sent Grace and Nelly off on exhaustive “needs evaluations” which produced impossibly long lists of everything from reliable water and electricity to ambulances , needles and suturing thread. We could never possibly set out to “supply” these needs, and even asking the question generated certain expectations that would lead to disappointment. But gradually, over the past seven visits, people there have come to realise that we really are just ordinary people, not some huge international organisation with limitless resources. And so, we can’t do a lot except take an interest, pay for some practical improvements, and, crucially, involve the people who deliver babies, and the people who train them, and the ministry who employ them, in devising simple, realistic ways to make birth safer, in hospitals and in homes.

Goodwill

We work as volunteers and our money comes mostly from small donations by individuals, who donate or organise fund-raising events. So the fuel we run on is goodwill, and I do believe that goodwill is catching. Following our 2009 visit, midwives from the Chad Midwive’s Association started doing shifts in the National Reference Hospital maternity (due to concerns about persistently high death rates there) to provide much-needed supervision. They did this voluntarily, on top of their jobs.

Now we hope to be involving these leading midwifery teachers in talks with the Health Ministry to devise a way that part of their paid work is supervision and practical teaching of students in the delivery rooms. This is the key intervention needed to raise standards, and we put forward a proposed agreement on these lines, to the Ministry in April 2011.

Solutions

We have attempted, but failed, I am glad to say, to find “strategies”. big ideas, “solutions” . Rather , we have muddled through with a handful of active people and a few loyal supporters. Looking back, I now think Africa doesn’t need people who have no idea what it is like to live there as a poor person, to think up smart ideas or make big plans for it.

We have had the advantage of sound advice from Grace and Nelly, “ Keep it simple, keep close to the people on the ground”, “ invest in the human resources”.

 

We have provided a few things which have made a practical difference – water, toilets, delivery kits, some drugs , but most importantly, we have shown an interest, we have cared, we have catalyzed a sense that change is possible – and a realisation that we are not the ones who can make it happen. The BBC film showed an American researcher called Jeremy Shiffman, who said the key factor was “political will”. What we forget is that political will doesn’t have to originate from politicians. In fact, it rarely does. It comes from ordinary people wanting change. When people can see that change is possible, and in their hands, then they start to want improvements. At the end of our 2009 visit, the Chad midwifery trainers sat down with us. One of them said to the others “ Look, these people come all this way because they care about our maternal mortality. But it’s our problem – they can’t solve it for us. What are WE going to do about it?”

In 2005, there was no active Chad Midwives Association . By 2011, CMA was an active body with a membership including the majority of midwives in Chad. The CMA now has an office and a small grant from the UNFPA.

In response to seeing the Panorama film when it was shown in Chad,  President Debe decided to build a new “Mother and Baby” hospital, to replace the maternity unit of the National Reference Hospital. This opened its doors in May 2011.

Also in 2011, we were successful in our first application to an institution for funding. “Wales for Africa” agreed to part-fund the cost of training visits to Chad. We still need our supporters to meet the majority of these costs.