Midwife Anabel Margaret (not real name) attached to one of the six hospitals in Uganda’s Busoga sub-region in the East of the country finds herself on duty alone one fateful night. She’s not only delivering mothers but must also keep an eye on five sick newborns admitted to the newborn special care room in the hospital.
Amidst this, she gets a mother in preterm labour at 28 weeks of gestation, in the second stage of labour who subsequently gives birth to an asphyxiated premature weighing 1200 grammes. Baby is resuscitated on the labour ward before being admitted to the newborn special care room. Using her recently acquired skills right from providing warmth, CPAP, establishing an IV line (takes six hours to succeed) for administration of drugs to bagging for several hours, Margaret has given it her best. But baby fails to thrive and dies. And through all this, there is no doctor in sight, as is usually the case at this hospital.
Margaret’s story was among the six shared during the just ended 5th Learning Session of a quality improvement collaborative under the East Africa Preterm Birth Initiative (PTBi-EA) Project. In the Ugandan arm, the project brings together six hospitals including Jinja Regional Referral, Iganga, St Francis-Buluba and Kamuli General and Kamuli Mission and Bugiri. The project aims to reduce morbidity and mortality from preterm birth by strengthening facility-based care from pregnancy through labour, delivery, and immediate postnatal period.
As teams reported back on a task of reflecting on the most recent preventable preterm death at their respective facilities as earlier put to them by PTBi-EA’s Quality Improvement Consultant Dr Nana Twum-Danso, it was evident that human resource constraints, knowledge gaps and some “unsupportive” medical officers were among the leading facilitators to the shared case fatalities.
However, in a setting where midwives and nurses cannot proceed beyond a certain point along the continuum of newborn/preterm care, it was the reported challenge of “unsupportive” medical officers that dominated discussions during the session and the subsequent district health managers and hospital leaders’ meeting to discuss continuous quality improvement.
One of the PTBi-EA mentors who is an OB-GYN (Obstetrician-Gynaecologist) said they have over time observed that some of the reported unsupportive medical officers under such circumstances lack the knowledge to care for preterm babies [rarely focussed on in medical school] yet they cannot find time to attend free onsite skills building sessions as part of continuing medical education.
This was re-echoed by PTBi-EA Project Manager for Uganda Dr Gertrude Namazzi saying “where medical officers have expressed interest and are participating in the skills building sessions, preterm care has improved. But in some facilities where they have kept away there are challenges.”
Calls for policy change
Given the abilities that midwives and nurses have demonstrated concerning preterm/newborn care in the Busoga sub-region hospitals amidst the reported functional and or physical unavailability of medical officers, amidst legal and procedural encumbrances on the former, stakeholders are calling for policy changes and urgent engagement of the latter.
“We should not continue to burry our heads in the sand. The doctors are not there and even those appointed are practically not there,” said Kamuli District Health Officer Dr Aggrey Batesaki. “I have seen midwives perform miracles in the absence of doctors. I am advocating for a policy shift that allows midwives and nurses to prescribe life saving drugs and procedures. This will give them the confidence without fear of being blamed. The Ministry of health and partners should consider this urgently.”
Agreeing with this submission, Jinja Regional Referral Hospital Director Dr Edward Nkurunziza said times have changed with technology and advancement of knowledge allowing midwives and nurses of today perform what their colleagues could not do in the past and was only a preserve of doctors.
“We are increasingly having so many nurses and midwives who are degree holders and these even share some classes with doctors while in training. We should now get away from the legalities of what they can and cannot do and look at the realities on the ground,” Dr Nkurunziza argued. “If the doctors are few and we have nurses and midwives who can do something considering the safety of the patient, why can’t we adjust their roles and responsibilities so that we allow them to save mothers and newborns.”
PTBi-EA’s Uganda Principal Investigator and Associate Professor at Makerere University Dr Peter Waiswa concurred saying task shifting has been tried within the health sector with good outcomes.
“It was done with HIV/AIDS and malaria even without a policy in place. The same can be done in maternal and newborn care. But this can only work if nothing goes wrong. Once something goes wrong then problems arise. So, a policy on this is very important.”
Engaging the doctors
While acknowledging the challenges, Co-Principal Investigator and Senior Obstetrician Dr Lawrence Kazibwe however urged against immediate punitive measures, rooted for being less judgemental and giving medical officers a hearing and new beginning.
“I do not think they are beyond being redeemable. Not all of them are bad. We can win over these souls by talking to them and reminding them of their duties and responsibilities. And the earlier we do it the better. I believe they will change,” he counselled.
Dr Harriet Nambuya, a senior paediatrician and Co-PI with the PTBi Project in Uganda similarly recognised the problem at hand, calling on hospital and district managers to initiate and have regular engagement with the junior doctors.
“How regular do we meet these medical officers and give them feedback regarding their performance? We are talking result-oriented management right now. Give them feedback as work goes on,” Dr Nambuya contended. “At these meetings they can be asked about their performance. For example, how many scissors has one done say in a week? This will get them interested in their work knowing that they will be asked about their outputs every week.”
Occasionally visiting medical officers at their work stations is yet another measure that Dr Nambuya believes hospital managers need to adopt, in addition to spot checking or unannounced visits, which has been found to make doctors “interested” in their work, according to the senior doctor.
Noting that because some medical officers find a problem being trained together with midwives and nurses, according to Dr Nambuya, mentors were willing to facilitate special sessions for them if this is what would get them more involved in newborn care.
For the Iganga Assistant District Health Officer Ms Ruth Namusabi, with mostly younger doctors labelled as “unsupportive” and functionally absent, the Uganda Medical and Dental Practitioners Council in partnership with the Uganda Medical Association should organise a comprehensive pre-registration orientation focussing on ethics and responsibilities.
“Merely receiving papers and offering practicing licences upon payment of the required fees without preparing the doctors will not help much. Leaving them at the mercy of the leaders where they are employed won’t solve matters. In any case they will listen to the professional bodies than anyone else.”