BUGESERA-RWANDA—In Nyamata, a village town of Bugesera district, a 30 minutes’ drive south of Rwanda’s Capital City, Kigali, Jeanne Musabende’s husband is hanging out with neighbors when labour pains start grinding her.
It is about 9pm in the night, Musabende panics. She then calls a community health worker for help, even though no much she can do, except calling for an ambulance.
Musabende needs to be rushed to the hospital, concludes the health official. She calls for an ambulance, as she makes basic diagnosis, taking notes. At the hospital, one of the nurses picks the notes from the community health worker.
Musabende is informed there is no caesarian procedure because she already had contractions. Night duty nurses rush her into the labour ward. She shortly delivers safely.
Musabende is Rwanda’s maternal health success story; where Rwandan mothers give birth safely and to healthy babies. Mothers in Rwandan villages rarely undergo caesarean, thanks to Rwanda’s ambitious efforts to cut mortality rate.
The World Health Organization ranks Rwanda among 11 countries in the world that are vigorously fighting maternal mortality. In 2000, about 1500 Rwandan mothers out of 100,000 were dying while giving birth or after giving birth.
Today, fifteen years later, the number has gone down to 340, a 76% decline; one mark past the 75% target of the UN Millennium Development Goals’ target for 2015. Yet the country wants to record less than 300 deaths by 2015.
Globally, Rwanda ranks 34, behind Switzerland at 35. Singapore, Greece Estonia rank first respectively with less than 3 deaths only. Chad and Somali take the lead, recoding more than 1000 deaths.
Norwegian Prime Minister of Norway, Erna Solberg, whose country’s rate is 7, co-chairs the MDG’s advocacy group with Rwanda’s President Paul Kagame.
Solberg visited Rwanda early this month to discuss the progress countries are making to meet MDGs targets. She was all praises for Rwanda.
There is background context to Solberg’s understanding. Years following the genocide against Tutsis in 1994, Rwanda had less than five doctors and handful of nurses.
“Rwanda had worst experiences with regard to maternal mortality,” says Dr. Stephen Rulisa, an obstetrician-gynecologist and Head of Clinical Research Department at Kigali University Teaching Hospital. There were no any healthy facilities, equipment and the country lacked staff, he recalls.
By 2013 though, public hospitals had about 600 physicians, 451 midwives and 160 medical specialists.
What could have triggered Rwanda’s aggressiveness?
“It is a political commitment,” says Doctor Felix Sayinzoga, in charge of Maternal Health at the Ministry of Health. For example, he says, “There was commitment against unsafe home births.”
Step one, all villages, together with health facilities, were ordered to start recording health issues such maternal deaths and causes and available facilities. Step two, nursing schools were established and facilitated to start training under- qualified nurses.
Step three, emergency obstetric care trainings would be offered at all health facilities, and then equip all medical staff with basic maternal health skills. Then an executive decision was taken at the national level. It was decided the entire health sector undergo an overhaul. Government started constructing health centers in every district.
By 2012, 451 healthy centers had been constructed, including 41 hospitals. Four national referral facilities received robust upgrades.
But that would not solve every problem. In the remote Rwanda, pregnant women would still be taken to the hospital while in critical condition. Some ended up dying during labour, says Peace Nyirarukundo, a midwife at Nyamata ADEPR Hospital, a Pentecostal-funded facility.
“They were too poor to afford medical bills,” she says.
In 2003 the government had to establish a Community-Based Health Insurance system known as Mutuelles de Sante, covering the costs for the indigent population and vulnerable groups.
The health scheme came at a time when many districts had dilapidated public health infrastructure with some districts having no hospital at all.
The lucky districts had one physicianwho would serve a population of over 320,000, with scarce electricity, water and sanitation services.
Health indicators were poor. Diseases had found a safe haven; and maternal mortality rate was despicable. But the country kept on the fight.Today, more than 92% of the population has health insurance coverage, literally covering all mothers in Rwanda.
As government build more hospitals, and trained more medics, it increased their basic salaries to motivate them, and regularly awarded outstanding medics following quality and quantity work.
But there again,the government maintained a firm focus on maternal mortality. The ministry of health created a surveillance committee at each healthy centre to audit cases and causes of any deaths of expectant mothers.
“The causes and factors of the deaths are identified,” adds Dr. Sayinzoga. A verbal autopsy unit, comprising of health center staff and community health workers, was put in place to report maternal deaths.
But all efforts had to be supplemented by a national-wide senstisation campaign about maternal health. Until today, women are advised on the benefits of antenatal care visits, proper diet during pregnancy, breastfeeding, and all mother-child health concerns.
Community health workers visit homes to monitor possible pregnancy, and then report to health centers. The information is collected and sent to the district hospitals. Currently, the task is conducted with sophistication through the ‘Rapid SMS’.
The system helps community health workers share patient information with the health facilities via mobile phones. “It is done to ensure all pregnant women attend all the four antenatal visits during pregnancy,” says Eugenia Mukamusoni, a community health worker, in charge of maternal health in Nyamata.
Had it not been for this program, which is mandatory especially to village mothers, the expectant mother Musabende would have put herself and the third born at risk.
Rwanda is a committed society
As the government plays its role, thousands of village folks have signed up to volunteer as community health workers, taking training courses offered by government.
Many of them can now treat diarrhea, malaria and pneumonia, among and offer counselling services. Each village has three health workers, 2 in charge of infant health, and one in charge of pregnant women. They report to the nearest health facility. Some of these volunteers include traditional health workers.
Many of them help government roll out sensitization campaigns. The campaigns, for example, minimize the risk of HIV positive mothers infecting their unborn babies, says Kenneth Ruzindana, a medicine student specializing in obstetrics at Kigali University Teaching Hospital.
Through these health workers, mothers regularly go test for HIV. Once a mother is found HIV positive, she gets extra attention to avoid infecting the unborn baby,” says midwife Nyirarukundo.
CallixteNsengiyumva is a community health worker. He says health workers follow up closely on pregnant mothers. “We help mothers give right reports to health centers,” he says.
Currently, district have to sign performance contracts with the President. Florence Uwayisaba, the Vice Mayor in charge of Social Affairs, Kicukiro district in Kigali City, says one of the pledges they make is combating maternal and infant mortality.
There is a still long way
While the Sub-Saharan Africa accounts for 62% (179 000) of global 289 000 deaths, with a few exceptions like Rwanda.
But Rwanda is not yet happy with the numbers. With high illiteracy levels, close to 50% of the population, a gap in skilled health specialists makes things more complex. A doctor still attends to 15,428 patients per day. The world health organization says 45.8% of member states have less than one physician per 1000 population.
While the country is heavily investing in high-tech hospital equipment and rolling out more health centers, hundreds of doctors are being trained. Beginning of July, the military launched a campaign to construct more than 500 health centers across the country. Over 40 health have been built and the project is expected to be completed by 2014.
Back to the Nyamata hospital, new mother Musabende is all smiles. “I was afraid of losing my baby,” she says, while codling her bouncing baby boy.
By Lillian Gahima