How three District Hospitals achieved zero maternal deaths

Minister for Health, Diane Gashumba addresses participants during an event recently. Sam Ngendahimana.

In developing nations,when a pregnant woman is giving birth, the experience can be both exciting and frightening since women worry about childbirth complications or the dangers of dying during the process.

The good news, however, is that in Rwanda, a soon-to-be mother at Shyira District Hospital in Nyabihu District, Kacyiru District Hospital in Kigali and Ruli District Hospital in Gakenke District can breathe a sigh of relief.

The Minister of Health, Dr Diane Gashumba, recently congratulated the trio because they “have managed to reduce maternal deaths to zero for the past seven months.”

“Congratulations! We encourage others to do the same,” the minister noted, on social media.

The World Health Organization (WHO) defines maternal death as the death of a woman while pregnant or within 42 days of termination of pregnancy. This is irrespective of the duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

According to WHO, every day, approximately 830 women die from preventable causes related to pregnancy and childbirth and, 99 percent of all maternal deaths occur in developing countries.

A quick inquiry into the way of doing business, and mindset, of the three hospitals indicates that the feat can be successfully replicated.

At Shyira District Hospital, a rural faith based and government subsidized hospital established by a British Anglican Church Missionary Society in 1931, devotion to community sensitization and enhanced communication are valuable tools.  

Maj. Dr. Emmanuel Kayitare, the Director General of the facility told Sunday Times that their main catchment area covers 16 health centres serving a population of 312,872.

The facility also serves people from 10 health centers in the neighbouring Gakenke Muhanga and Ngororero Districts.

“Every month, we receive and care for at least 150 mothers and we are expecting more. The Ministry of Health recently deployed to Shyira District Hospital three junior consultants including a gynecologist to increase health capacity building.”

The others were a pediatrician and an internist, he said.

Asked how many medical professionals attend to pregnant women, Kayitare said they have two doctors, one in the emergency room and another in the labor ward. Then there are three midwives.

Kayitare added: “I can’t forget the use of drones (Zipline) for blood deliveries where it is required as an emergency.”

The drones, he acknowledged, are also positively impacting on how they care for pregnant mothers.

“A pregnant woman may need transfusion before or after caesarian section, or in other different conditions according to her low hemoglobin; even by spontaneous delivery it can happen.”

But how did they really bring maternal deaths to zero? According to Kayitare, constant meetings and advice to health centres are bearing fruit.

They convinced heads of health centres to, at all times, send pregnant women in their areas of operation to Shyira District Hospital “early, or on time” so that they get attended to.

He said: “We spend about a week with an expecting mother and give her intensive care. We are tireless when it comes to raising awareness using our community health workers. It is really not about us having any special equipment.”

“Our hospital is located high out in the mountainous territory where transport is not easy. We advise patients to come early so we avert risks. The meetings we conduct with managers of health centres are paying off because pregnant women show up early.”

Women with previous cases of hypertension, caesarian uterine scars, a history of previous preeclampsia, diabetes, and others, are often followed and advised to report for early medical care.

At Ruli District Hospital, a faith based hospital owned by the Catholic Archdiocese of Kigali, ample effort is also put in to stop maternal deaths, according to Dr. Deogratias Kaneza, its Director General.

It is one of the two District Hospitals of Gakenke District. It is built in rural Ruli Sector, in the Northern Province, and mainly serves a population of 109, 998 people.

The hospital’s nine general practitioners – including one specialist – diligently serve nine health centers; Ruli, Coko, Minazi, Muhondo, and Rukara, Rushashi, Muyogwe, Rwankuba, and Nyange.

And as if that were not enough, these nine doctors also serve seven additional health centers in Rulindo, Muhanga and Kamonyi Districts, “outside our main catchment area,” said Kaneza.

But despite challenges such as an unfavorable rough terrain, Kaneza said the “teamwork” between health centers and the hospital was pivotal. A well-structured referral system, he said, and good communication is crucial as well.

“We have a place called the maternal house; where pregnant mothers from far off rural areas stay freely while they wait to have their babies.”

The maternity house, he explained, was found to be a necessity since the hospital is located in difficult hilly terrain.

Just like at Shyira, the rural and often underprivileged pregnant women with caesarian uterine scars and other risky health conditions are given a temporary home and very special attention early on. They need to stay at the hospital for some time because trekking back home is a challenge.

“We usually have eight to 12 women at the maternal house. Others are elsewhere because we have 40 maternity beds. As they wait, usually for two weeks, we teach them many things including maternal health, sanitation, tailoring, and so on.”

Other country hospitals, Kaneza said, can replicate their methods so as to stop maternal deaths.

“It is not so hard to do. It is just a matter of seeing things the right way and working to reduce maternal deaths. It can be done.”

Unlike rural Shyira and Ruli settings, Kacyiru District Hospital is in urban surroundings. But here too, the theme of dedication to the cause is similar. When The Sunday Times visited last week, the compound was a hive of activity. Outside a maternity ward, a security guard and a midwife were busy sending guests off. It was past visiting hours and doctors had to attend to the patients.

There were no more than seven well-spaced beds inside the wards, most occupied by mothers and, their newborns. The peace in the room was only disturbed by a brief pounding of a workman’s hammer outside.

Two mothers, Jackline Kayitesi, 24, and Esther Mukeshimana, 38, accepted to talk to this reporter.

Kayitesi, a Burundian refugee who gave birth to her first child, a boy, on October 11, only had praise for hospital staff.

“They received me with open arms and gave me the best care I have ever seen. I haven’t lacked for anything despite the fact that I came in here alone and have no next of kin to visit me,” Kayitesi said.

Her baby had an infection and the doctor advised they stay a little bit longer.

Mukeshimana’s story was more revealing. She bypassed Muhima Hospital, in Nyarugenge District, which is near her home and, “walked all the way to Kacyiru” to deliver her fourth child, a boy, on Monday.

“A neighbor told me pregnant women get the best care at Kacyiru Hospital. That is how I resolved to come. I couldn’t go back to Muhima,” she said.

Her first three sons were delivered at Muhima Hospital, memories of which she recalled with sadness.

“Of late, every time I went for checkup they sent me back yet my due date was three weeks overdue. I was worried. Last weekend I decided to walk here. From the entrance where I met security guards, and the nurses who first talked to me, everyone here is kind.”

She was given an appointment on Sunday but failed to make it. When she showed up after a laboring walk, on Monday, the petty grocery trader was “not scolded” as she had dreaded.

“My experiences at Muhima are nothing compared to here. Their services are poor yet they charge a little more money too. People here are kind,” she said, fighting against the urge to cry.

“Today [Tuesday] I was discharged but couldn’t move as my husband is yet to find money but I was not mistreated. I am allowed to keep my bed, without extra charges as I wait. At Muhima, it was totally different; they wouldn’t mind moving you to the corridors, or the floor.”

As this reporter walked out of the hospital, a member of the hospital management team explained that their way of doing business is guided by one general principle; MBWA, or “management by walking around.”

This, he explained, is a style of management which involves “all of us constantly moving, without warning,” through the hospital to check on the status of ongoing activities.

Driven by empathy

ACP. Dr. Daniel Nyamwasa, the Director General of Kacyiru District Hospital, told this reporter that “it is not easy to explain zero maternal death in our work situation.”

Asked what makes his hospital stand out when it comes to stopping maternal death, Nyamwasa first pointed out that “the leading cause of maternal death in our settings (Rwanda) is postpartum hemorrhage (PPH),” or excessive bleeding after childbirth.

Disaster, he said, is avoidable once immediate or “close post-partum monitoring” is properly done.

“Complications are identified on time and action taken quickly.”

Second, he said, most maternal death is due to infections which are prevented once appropriate measures are taken.

“Most maternal death cases are preventable. These require: skills, human resource and working with professionalism, in addition to applying evidence-based medicine. Our administration is fully involved in priority patient care.”

There are multiple factors, he noted, including strong hospital administration, medical staff in general, and commitment by all.

Their magic, Nyamwasa explained, is possibly in their entire methodical process.

“Every day at 07h15 hours, our medical staff discuss the most complicated cases (patients) and daily work briefing from hospital management. On this platform, administration is aware of any obstacle to patient care and duly sorts out any issues presented.”

This implies, he said, that administration and clinical staff work closely, on a daily basis.

“This has a positive impact also in terms of logistics; administration timely provides anything needed as it is correctly updated by morning staff meetings.”

At the hospital, he added, their skilled medical doctors and nurses are motivated and fully committed to work.

“We provide prenatal care and post-partum care (follow up). Patients are discharged with clear instructions of their conditions. They are given a phone number to call for advice should need arise and know they can come back to hospital if necessary. Our health professionals are driven with empathy.”

editorial@newtimes.co.rw