By Amy Dempsey & Saumya RamaRao
Death during childbirth or pregnancy is a common occurrence. It happens 830 times a day, most often in developing countries. Pre-eclampsia and eclampsia (PE/E) is the second leading direct cause of maternal mortality worldwide. And that is terrible, not only because women in developing countries are 300 times more likely to experience PE/E than women in developed countries, but because we know how to stop these deaths from happening.
For decades, the medical and global health communities have viewed magnesium sulphate (MgSO4) as the gold standard for PE/E prevention and treatment. We know it works faster and better than other anticonvulsants like diazepam, but in many settings diazepam is still administered instead of MgSO4. So, why then, are the women who need it unable to get it? The reasons are many, but one is the lack of capacity among the existing health workforce. If more health providers – those based at primary and secondary health facilities – could administer MgSO4, more women and babies would survive PE/E.
The health workforce, one of the World Health Organization’s (WHO) six building blocks of a high-functioning health system is the primary focus of this blog. First, how do we define the term? A health workforce is made up doctors, nurses, midwives and skilled birth attendants at primary, secondary, and tertiary facilities, as well as community health volunteers, and public and private pharmacists within communities. Trained and skilled health care providers stationed closest to the community increase access to users, which is especially vital in countries with low service utilization. They also create linkages between individuals seeking care, communities and other frontline health care providers, such as pharmacists or community health volunteers. Deployment of a well-trained workforce increases efficiency and cost-effectiveness of the health system. However, trained health care providers are as important as they are in short supply.
USAID reports that there are 18 million fewer health professionals in the world than what is needed (USAID 2016). The largest shortages are in parts of Asia and in sub-Saharan Africa. On education and training, for example, in the 47 countries of sub-Saharan Africa, there are just 168 medical schools. Of those countries, 11 have no medical schools, and 24 countries have only one (WHO, 2013). This implies that large numbers of women do not have access to skilled health care. We also know that many women seek advice and services from frontline health providers.
To minimize this gap and improve maternal and newborn health outcomes, including those related to PE/E, the WHO recommends task shifting. Task shifting must be contextually appropriate, but it is a way of using resources (human and financial) more efficiently. It assumes that health providers at all tiers of a health system can diagnose, treat, and prevent deaths of women and their babies. In other words, task-shifting and/or task-sharing allows lower qualified health care providers to perform a range of services previously provided by a higher qualified provider; by doing so, higher qualified providers can thus focus on those tasks that require greater clinical skills.
We have seen this be successful in many aspects of sexual and reproductive health. Skilled and traditional birth attendants in Madagascar and Mozambique were able to prevent death from hemorrhage when guidelines were changed to allow them to administer misoprostol. Unintended pregnancies are reduced when midwives can insert contraceptive implants and intrauterine devices (IUD) and when pharmacists can provide contraceptive injections. If frontline health workers, such as nurses and midwives can provide these clinical services, then surely they can administer a loading dose of MgSO4 and refer PE/E patients to secondary facilities for further management. This would bring necessary services closer to women and their families, reducing a major barrier to their access to care. It would be put us a step closer eliminating preventable maternal and newborn deaths.