Poorly-regulated, privately-run training schools in Senegal are churning out midwives who do not have a solid grasp of birthing or ante- and post-natal care, causing women and babies to die needlessly, according to the UN Population Fund (UNFPA).
Other basic competencies, as defined by the World Health Organization, include referral in high-risk pregnancies or births; addressing miscarriages; and family planning.
Most women who die during labour in Senegal do so because of post-partum haemorrhaging, according to UNFPA’s joint Senegal director, Edwige Adekambi.
“We know the causes of maternal mortality; we know that if a haemorrhaging woman does not get care within two hours she is likely to die, but many private training schools don’t even include this care in their curriculum,” she told IRIN.
Some 401 women died per 100,000 live births in Senegal, according to the latest government health survey in 2005, ranking 144 out of 181 countries studied; and only 52 percent of births in 2005 were accompanied by a qualified birth attendant, though for the poorest 20 percent of women this drops to 20 percent. While performing better on maternal mortality than most of its West African neighbours, Senegal still has a lot of work to do to reach the Millennium Development Goal on maternal mortality, according to UNFPA.
These and other issues were discussed at the Senegal launch of UNFPA’s State of the World’s Midwives report on 29 June.
Senegal has dozens of private midwife training schools which are in theory, regulated, but with just two government inspectors to do this, many get away with low standards, said Adekambi.
Bigoué Ba, vice-president of the National Association of Midwives, told IRIN “Anyone can open a school in Senegal. There’s no monitoring.”
While there is a national test that all midwives must pass to be recruited into a public hospital or clinic - and generally those who pass have been trained in public institutions, according to UNFPA - many who fail the exam can still obtain a diploma and find a job in a private clinic, said Adekambi.
The government has tried to improve regulation of schools, but cannot be expected to do it all, Health Minister Modou Diagne Fada told journalists at the report launch. “We are committed to improving maternal mortality rates and addressing the midwife problem, but partners have to help with this too,” he said.
UNFPA is working with the government, the National Association of Midwives, and aid groups to improve the national curriculum; it calls on the government to impose stricter regulation across the sector.
The current curriculum, while thorough, excludes vital aspects of birthing support, including how to administer antibiotics, to give oxytocin to stimulate uterine contractions; and using ventouse (a vacuum device) during birth to ease delivery. UNFPA teaches these techniques in “post-training” for midwives in several regions including Kolda and Tambacounda in central Senegal.
As well as better training, more midwives are needed across the country: Senegal has just two midwives per 1,000 population, which is one-third of the recommended international norm, according to WHO.
|Density of midwives, nurses|
and doctors per 1,000 population
|Sierra Leone 0.2|
Shortages are particularly acute in rural areas: Matam, on the eastern border, has just 14 state-trained midwives and requires 389; Tambacounda has 38 (only one of whom is trained in family planning) and requires 515; while Dakar has 445 but requires a further 1,566, according to 2008 statistics from the Ministry of Health and Prevention’s human resource unit.
There is no gynaecologist or obstetrician at all in Kolda, so for complicated births women have to travel to Tambacounda, which takes more than the precious two-hour window, if something goes wrong.
To reach Millennium Development Goals four and five to improve child and women’s mortality and health, Senegal needs to recruit 250 additional midwives per year, according to UNFPA.
In 2010 the government did a countrywide recruitment push, hiring hundreds of additional midwives to work in rural areas.
While partially successful, half of all midwives recruited to rural areas “found a reason why they had to return to Dakar within the year,” said Health Minister Fada.
He puts the onus on them to stay. “It is their duty if they accepted this profession, to work where the needs are,” he told journalists at the report launch in Dakar, and he also called on the Midwives’ Association to encourage midwives to stay.
But the government also needs to think of more creative ways to encourage midwives to work in rural areas, said Ba of the National Midwives Association. Incentives have been discussed but few yet put into practice. These include providing midwives with lodging, a vehicle, health insurance for their families, or career development training.
The Health Ministry should also consider training up the hundreds of traditional birthing attendants, known as “matrones”, who work in villages throughout the country, said Ba.
More also needs to be done to make midwifery an “attractive” career, according to Ba. Midwives are paid on average US$200-300 per month at first but, given that there is very little career development, this could rise by just $100 over two decades of work. Career development training would also incentivize women to commit over the long term, she said.
All recognized the progress the Health Ministry has made since 2010: trying to regulate training more carefully; requiring the minimum of a baccalaureate certificate to enter midwife training; and delegating more medical tasks to midwives.
Most significantly, the government made all births, including Caesarean sections, free of charge in all regions of the country, except Dakar.
Further improvements will cost more than recent additions to the health budget will allow, said Fada. New income sources for the health sector, such as additional taxes on cigarettes and other goods, are being considered.