I want to start with my perspective of maternal and child
health in the developing world, before the lecture at FHI360.
My cousin has come to the United States from Egypt, for a very
particular reason: not to gossip with her American relatives, not to see how
numb her extremities get in the Chicago winters, and not to admire the country
that made the Kardashians famous. She comes as a medical tourist to have her
children. Controversy surrounding the
logistics of this aside (yes this makes them all US citizens- added bonus) she
does this because she does not feel safe and does not feel her babies would be
safe being born in an Egyptian hospital.
The thing I would like to highlight here is that my cousin
is obviously not impoverished she is spending thousands of dollars to come to
United States to have her children, this means that she has the means to access
to best medical care in Egypt, and
even that is not dependable—or in a western mindset—up to a developed country’s
standard. The things that she fears and
the issues her friends and family members’ have faced all surround pre and
post-opp care. There are trained obstetricians that she has access to, but the
hospitals do not have the means to prevent and fight possible infections or
complications post childbirth.
With this I look to the research Emily, Caleb, and Seth are
conducting, and the similar model of research conducted in Ethiopia. While we cannot make direct comparisons
between developing countries’ medical infrastructure to support women and
children, we can compare them to predict and understand issues that keep these
women and children unsafe (note that as
we saw in the countdown to 2015 decade report, Egypt had 3 times the amount of
caesarian sections Ethiopia and Mozambique have, suggesting that Egypt is a
country with more access to high function medical care).
Do you think that this stretch is reasonable and that such
comparisons are telling of what issues should be highlighted? Basically, do you
agree that this comparison is one worth making or do you think I’m throwing the
wrong information in the wrong places?
Current status (Model 0) of Tier B catchment areas by
2-hour transfer time to a Tier A facility
We saw through Seth’s GIS model of Mozambique and the
article on Ethiopian access to care that there are certain regions that are
lacking access to a high functioning medical facility, and both Emily and Seth
referenced the long-term idea that if access is increased, this may encourage
more women to have their babies in a medical facility. Off the basis of what my
cousin has witnessed in Egypt, I think there might have to be particular emphasis
on post-operative care, not just medical resources. Even if more regions of Ethiopia and
Mozambique are in reasonable proximity to a high resource facility, risk of
infection is reason enough to stay away.
I recognize that maybe the first hurdle for these countries
is to have these greater resources, but maybe this post-op care and lowered
risk of infection can happen hand-in-hand instead of struggling to
retroactively establish strict anti-infection protocol into a running system.
What are people’s thoughts on the feasibility of
incorporating both of these qualities into health facilities in Ethiopia? There
has to be a reason why they’re not already in place, do we think these
obstacles are too great to expect high functioning, infection free facilities?
Thanks, Deena, for your thoughts on this very complex problem of how to improve maternal and obstetric care in low-resource settings. I have a few thoughts to offer to your discussion: one regarding the particular needs of a childbirth facility; one regarding the challenge of infection control in these settings; and one regarding comparing countries such as Ethiopia and Egypt.
ReplyDeleteFirstly, it seems women have many different reasons for deciding where to deliver their children. One of the most common driving factors in the developing world is a woman’s financial resources (along with her husband’s wishes). If a woman does have the luxury to decide where to deliver, as did your cousin, she might chose a particular hospital or health center based on location or reputation, rather than true medical capacity. When we, as global health scholars, are actually evaluating the capacity of a particular facility, we might want to distinguish between their C-section rate and their true obstetric competence. One might argue that the best OB’s would have a lower C-section rate for routine deliveries—as this procedure should only be reserved for the most high-risk women and babies. Certainly a woman would want to know if a facility could handle a C-section if the need arises, but the sheer number of C-sections performed might be more reflective of an OB’s training than of a facility’s medical capacity. Another interesting parameter to consider might be the rate of babies born with anoxic brain injury (a common complication of a poorly-managed delivery) as a gauge of competency.
Second, the problem of infection control… this is a common theme among many public health initiatives in developing countries. In fact, a project cannot—and should not—attempt to begin any sort of intervention without first considering the infection risks and control measures. Presumably, the efforts in Ethiopia to scale-up delivery centers would also include an infection control component. This might be more difficult if facilities do not have access to running water, or a regular supply of rubber gloves. However, we hope development projects would also incorporate these very basic, but essential, components.
Finally, on the issue of comparing two different countries: I’m curious to hear others’ opinions on this. In my mind, though we can certainly learn from the successes and failures of other countries, it seems extremely difficult to plainly compare one country with another-- as they have entirely different contexts, histories, and hierarchies of power. It’s even quite difficult to compare different regions within one country! I do think it’s important to recognize common themes in low-income settings worldwide—such as geographic barriers to accessing health-care, sociocultural barriers to accessing birth control, and financial barriers to properly managing chronic diseases. However, as each particular country has very different reasons for their particular barriers, their solutions will thus also be quite different—and unique to that particular setting.
So in summary, comparing Egypt and Ethiopia might shed light on common challenges in global maternal health, and it might therefore be a valuable exercise. However, devising a solution to those challenges may require longer conversations with women such as your cousin, and others who can speak from experience.
Deena, for your sharing your perspective on maternal and child health, as well as your thoughts on improving Ethiopia’s health care system. Regarding the comparison of countries, I think that it can be done, but should be done with caution and on a case-by-case basis. As Emily already referenced, given the different cultural contexts, histories and power structures that may be seen between countries it can be a very difficult comparison to make. That said, while the overall health systems between two countries, say Egypt and Ethiopia, may be vastly different, making comparisons and comparing between similar regions of the countries may be justified.
ReplyDeleteIn terms of improving the risk of infection in hospitals, this was the part of the talk that was most unsettling to me. I have seen a number of health care facilities in different developing countries, so the general idea wasn’t that alarming to me. But the scene they described of a women delivering a child next to a man dying of pneumonia painted a grim picture. And that many of these facilities also lack adequate medical supplies and clean water makes the risk of infection that much higher. Unfortunately, as I see it, these trends probably won’t be changing any time soon. To build separate wards, ensure a supply of clean water, and consistently provide necessary medical supplies would require HUGE amounts of money, and this I think is the greatest obstacle that countries like Ethiopia face when trying to change their health care facilities.
Hi Deena, thanks for sharing your personal story as well as thoughts on comparing Egypt and Ethiopia. Coming from India, I do agree with you in that maternal care, particularly post-operative, need a lot of improvement in many countries. However, I am not sure if the model that was discussed was very comprehensive in taking into account the decision making factors of poor women who needed care. For instance, given 3 choices between top-tier, middle-tier and lowest-tier medical facilities, I am not sure that the women would pick the top-tier one. The local people are aware of many hidden costs associated with the higher service facilities despite treatments being advertised as free. The local biases, road conditions in different seasons, population densities in certain areas must all be taken into account to develop a holistic model, that can then be applied to other countries and settings.
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