Born in Liberia

Struggling to persuade pregnant women to use clinics to give birth rather than stay home, this African country finds coercion is one way to do it

(AFP/Getty)

Evelyn Dolo saved a teenage girl’s life but not out of goodwill alone, she says.

A traditional birth attendant for more than 15 years in the small Liberian village of Zahmboyee, Dolo was summoned one night to help the teenage girl deliver her baby. Dolo rushed the girl to the nearest hospital, about 25 miles away, where she was immediately taken into surgery.

A cesarean section saved both the girl and her baby’s life, says Zlangbah Dahn, head of obstetrics and gynecology at Ganta United Methodist Hospital.

Dolo’s objectives in the case were twofold: she was racing to save the girl’s life but she was also compelled to rush to the hospital under the rules of her village. Rather than deliver women’s babies at home, birth attendants in many villages are required to bring pregnant women to health centres or face penalties. In Dolo’s village failure to comply would have meant a payment to the town elders of 5,000 Liberian dollars (around £40), a gallon of palm oil and a tub of cooked rice.

The local policy essentially forces women to give birth in health centres by threatening financial penalties – a practice aimed at curbing maternal deaths. In Liberia 725 women die for every 100,000 live births – among the highest rates of maternal mortality in the world.

The practice is not a national policy regulated by the Ministry of Health, although the Liberian government does encourage women to give birth in health facilities as part of its push to lower maternal deaths in childbirth. Instead, it varies from one community to the next. In some villages the fine is much lower or offenders must pay in cattle. In others, the nearest health clinic levies the fine rather than the town leaders.

A Big Belly business poster encouraging women to discuss the option of going to a hospital when they are pregnant (Nicholas D. Kristof/The New York Times)

Local clinicians say they are seeing more women deliver in hospitals as a result. “It’s working,” Dahn says. “Home births still happen in the village but more birth attendants are bringing women here.”

Experts in the US, however, fear the practice might deter those who deliver at home from visiting a hospital or a clinic for other healthcare. It is also unclear if the practice actually saves more mothers’ lives.

“This is a very complex issue and something like a penalty is a blunt instrument,” says Lynn Freedman, director of Columbia University’s Averting Maternal Death and Disability programme. “I don’t think it gets countries or their populations where they want to be.”

Coercive measures can set up negative associations with the healthcare system, she explains. It could make mothers who deliver at home reluctant to bring their children to clinics for vaccines or other care, fearful that they might be treated as delinquents who broke the rules.

The idea of using fines to enforce certain maternal health behaviours is not a new concept but it is fairly rare. Punitive measures to get women to deliver in hospitals have also cropped up in villages in Zambia, Tanzania, Malawi and the Philippines, Freedman says.

Other countries, including Nepal, Cambodia and India, have incentive programmes rather than coercive measures. In India, where the government gives women cash to deliver in a hospital or a clinic, institutional deliveries increased to 49 percent in 2010 from 20 percent in 2005.

The goal of these programmes is twofold: to ensure a woman has easier and quicker access to a C-section if she needs it, but also for her to be assisted by a trained midwife rather than a traditional birth attendant.

While traditional birth attendants have historically played an important role in supporting pregnant women in rural areas, they may be untrained and may sometimes follow dangerous practices. In Liberia, some birth attendants will roll a pestle on the mother’s stomach to try to push the baby out, says Eunice Josiah, a registered midwife at a health clinic in Boegeezay. The practice can rupture the woman’s uterus, endangering the lives of both the mother and child.

Another problem is that birth attendants do not have the surgical tools that a health centre can provide. For example, if a woman is in obstructed labour, where the baby cannot exit the uterus, a birth attendant cannot perform a C-section. By the time the woman reaches a hospital, it is often too late.

That was the case for a woman from a rural village called Yarnee. She went into labour on a Friday and continued the process at home for three days before someone suggested she should go to a hospital, says Dr Mamady Conde, the only full-time practising physician in that county. That was when she and her brother began the nearly two hour walk through narrow footpaths in the forest, followed by an hour-and-a-a-half canoe ride to Cestos, the city where the nearest hospital was. By the time the canoe reached the shore, the woman had died, says Conde.

Dr Jeffrey Smith, an obstetric gynecologist who is vice president for technical leadership at Jhpiego, a not-for-profit health organisation based at Johns Hopkins University, said women and their babies who arrive at a clinic can get better access to ambulances that can take them to the nearest surgical centre.

“You have a minute, maybe three minutes, to resuscitate that baby if it’s not breathing at birth,” he said. “Being in a facility reduces the critical response time if there is an emergency.”

But these theoretical benefits do not always translate to the field. In India facility deliveries spiked after the cash-incentive program but there was no meaningful difference in maternal mortality rates.

Facilities cannot just exist as buildings, Smith says. If more women are coming into clinics, then those places need to have increased staffing and supplies to care for them.

“If you double the workload but don’t change the number of staff or the capacity of the health system, you have the potential to anger people and increase instances of disrespect and abuse toward the patient,” adds Smith.

A clinic in Boegeezay is working to address that concern. While it fines birth attendants 750 Liberian dollars for a home delivery, it is also trying to provide better care to make women want to deliver there.

The clinic has a maternal waiting home, where mothers can stay near the end of their pregnancy, eliminating the risk that they may go into labour in a village too far from emergency care. Each woman is given her own room and bathroom, as well as meals, free of charge.

The clinic also works with community health workers who are trained to help expectant mothers develop a birth plan that details how they will save money and arrange transportation to reach the clinic in advance of their delivery.

© New York Times