The Long Road to Rundu

In Namibia’s understaffed maternity wards, this training program can mean the difference between life and death.

Dr. Nkandu and his team had a decision to make. The situation was quickly getting worse for the woman before them as she struggled to give birth to her third child. She was showing some signs of obstructed labor—a Bandl’s ring had begun to form like a tight belt around her midsection, meaning that the two segments of her uterus were pulling apart. Both mother and baby were in danger, and the team needed to act. Should they attempt an emergency caesarian section on the spot, where the hospital had no anesthesiologist on staff? Or risk the hour-long drive west to the larger, more equipped Rundu Hospital?

Just a few months earlier, before they had gone through emergency obstetric care training, they would have made a different call. But on this night, Dr. Nkandu and the senior maternity nurse climbed into an ambulance with the laboring woman and sped down the long, dark road to Rundu. As they drove, the fetal heart rate dropped from 120 beats per minute to 95. They called Rundu Hospital and asked them to prepare the operating theater.

By the time the ambulance arrived, the mother was bleeding. And the fetus’s heart rate was still falling.

It wasn’t until they’d made the incision that they found her bleeding was caused by a uterine rupture, a painful and sometimes disastrous tear along the scar line in the uterus from a past C-section. Second, they could see that her placenta had moved down to block her cervix—a dangerous condition doctors call placenta previa. And complicating all this was the extensive scarring from the mother’s past C-section, which was causing her uterus to adhere to her abdominal wall.

Dr. Nkandu knew then that they would not have been able to save this woman if they had operated at Nyangana. They didn’t have the equipment or the specialists she needed. They did, however, have a strong working relationship with Rundu Hospital and the foresight to transfer the laboring woman there for her surgery.

“We would have had a maternal death—and probably a fetal death,” Dr. Nkandu says, “if it were not for the EmOC training.”

Charted terrain

The remote Nyangana Hospital is situated just a stone’s throw from the banks of the Kavango river, which separates Namibia from Angola. Some 40,000 people in Namibia’s Nyangana district rely on the hospital for all kinds of health care services. In one building, HIV-positive clients watch TV as they wait for their antiretrovirals. In another, tuberculosis patients convalesce apart from the other clients. And then, of course, there is the busy maternity wing.

Just a few months ago, some of Nyangana’s maternity staff members had gone through a four-week training program on emergency obstetric care, or EmOC, provided with USAID funding by IntraHealth International.

IntraHealth has been working to train health workers in Namibia to make sure they’re prepared for all kinds of maternal and newborn health emergencies. The three-week EmOC training teaches maternity ward staff basic newborn lifesaving skills, such as how to resuscitate a baby that isn’t breathing. It also shows them how to use detailed charts called partographs to accurately plot the progression of deliveries, to read warning signs during labor, and what to do when things go wrong, as they did that night in Nyangana.

Partograph—it sounds complicated, but it’s really a simple and powerful tool. Just a sheet of paper with charts and squares of varying sizes where health workers can record all the details of a delivery over time—cervical dilation, descent of the head, fetal heart rate, membranes, medications or fluids given, and more. The chart helps maternity ward staff to establish patterns and pinpoint signs of trouble. And while partographs aren’t new, the way health workers should be using them has changed.

“For example,” says IntraHealth’s Dr. Kudakwashe Chani, “previous teaching was that you didn’t start filling out the partograph until after the latent phase, which is when the cervix is only dilated by one to three centimeters.” Many health workers who haven’t updated their training for a few years are still following this old rule. The problem is that a lot can happen during that latent phase.

The old teaching was based on the assumption that a woman in labor only lingers in the latent phase for a few uneventful hours before entering the more action-packed “active” phase. But what happens when a woman is in labor for twelve or more hours before ever dilating more than three centimeters?

It means she’s in distress, Dr. Chani says, and that’s a warning sign.

Without those twelve hours monitored, charted, and documented on the partograph, signs of maternal and fetal distress could go unnoticed. And data about what the client has already gone through will last only as long as the shift of the nurse on duty.

The anesthesia dilemma

One of the simplest but most effective lessons health workers learn during EmOC training is to open the partograph as soon as labor begins. It helped Dr. Nkandu and his team at Nyangana that night, but the training segment on how to respond to emergencies is what truly saved their client.

Before the EmOC training, the Nyangana team says, they would probably have done what many other rural Namibian hospitals have done (and continue to do) when faced with that kind of crisis: attempted an emergency C-section, using only the skills and tools they had on hand, in an attempt to save the mother and baby.

But the risk is high.

Most rural hospitals don’t have an anesthesiologist on staff, meaning that the client gets only general anesthesia and an oxygen mask, rather than more specialized anesthesia and intubation. There’s always a good chance that the client will aspirate, or vomit, during the procedure. Without the right equipment, there’s nothing the health workers can do to keep the fluid from blocking her airways and drowning her.

Given the risks of a C-section without the proper anesthesia—and the lack of diagnostic tools such as a fetal ultrasound machine, which could have helped the Nyangana staff detect the placenta previa sooner—it’s often safer to transfer a client to a larger facility. (Of course, that’s not always possible. Some hospitals and clinics are many hours away from another facility.) Luckily, Rundu is right next door to Nyangana, by Namibian standards: just 108 kilometers away down a paved road.

A lot of things could have gone wrong for Nyangana Hospital’s client that night. But Dr. Nkandu and his colleagues had the benefit of a strong working relationship with the regional management team at Rundu hospital—the kind of connection that is key to emergency obstetric care in Namibia. And they had the information and the confidence they needed to save not only one woman’s life, but that of her baby as well.

“We were very happy that we made the right decision,” Dr. Nkandu says. “It was a very good outcome.”

IntraHealth’s Capacity Building for Country-Owned HIV/AIDS Services project in Namibia is funded by the US Agency for International Development. Nyangana Hospital is operated by Catholic Health Services. IntraHealth plans to continue providing EmOC training in the Kavango region and beyond. Dr. Kudakwashe Chani and other IntraHealth staff follow up with health workers who have gone through the EmOC training by visiting their facilities, answering questions, reviewing recent partographs, and providing supportive supervision, all as part of the IntraHealth-designed performance improvement approach.