Final Pieces

EDUCATION KEY TO MATERNAL HEALTH

By Ann Robinson

ACCRA, Ghana – Lining the paint-peeled walls in a stuffy hallway at the Police Hospital, dozens of pregnant women waited on rickety benches at the weekly antenatal clinic.

Since Ghana’s National Health Insurance Policy began offering free maternal healthcare in July, women have been pouring into clinics. On some days, more than 100 expectant mothers wait up to eleven hours for two minutes with the single obstetrician.

Most of them do not need a doctor, just reassurance. “They don’t know anything about themselves and their pregnancy,” sighs Florence Okra, a midwife and public health nurse.

Okra, also a childbirth educator, links the lack of basic knowledge about pregnancy and childbirth to persistent labor complications and maternal mortality.

According to the Population Reference Bureau, each year in Ghana an estimated 3,900 women and girls die from complications during pregnancy. Tens of thousands more are permanently disabled.

Believing education gives expectant mothers the tools they need to take care of themselves, Okra established Eve’s Foundation in 2000. The foundation offers pregnancy and childbirth classes.

Three years after it was launched, as many as 70 women attended the weekly classes held in Accra. Its tremendous success led Okra to register Eve’s Foundation in 2003 as a nongovernmental organization (NGO). She now hopes to expand the program throughout Ghana.

Okra identifies the main problem: “Women don’t have the skills to labor because they are not provided with the proper education, not supported and not given confidence.”

Hospital midwives and doctors, tending up to 100 women a day, can only offer limited antenatal counseling. Yet they are the only resource financially available to most women.

Even when offered education, some women “don’t want to rely on what we are teaching them. They want to take advice here, advice there, and then they get lost,” says midwife Alberta Markham-Segbafah.

Eight months into her first pregnancy, Katherine Adoctar, 29, often receives well intended but unhelpful advice. “People will tell you horrible things…things that are not true, so that you worry…Meanwhile, it’s normal!”

The common myth she has been told advises against eating eggs, believed to soften the baby’s skull and cause future headaches.

Adoctar is grateful for Okra’s pregnancy school. “If we have a problem we go to Madam.”

Another student in class, Lily Afeke, 31, attributes the pervasive cultural myths to ignorance. She also sees that many Ghanaians are skeptical about childbirth education.

“Most women think it’s a waste of time and money. It’s very difficult to convince them.”

Afeke recounts frequently rushing to the hospital during her first pregnancy convinced, but mistaken that, something was wrong. Her second time around she determined to better the experience. Due next month, she says, “From my first pregnancy to this one, I have seen a great difference.”

She attributes the improvement to Okra’s classes. “I was so happy to learn more about myself, how to take care of myself and…feel the joy that there’s a life inside of me; to be calm.”

Samuel Amo-Mensah, chief obstetrician and gynecologist at the Police Hospital, recognizes patients who have had childbirth education. “I can tell those who’ve been to [Okra’s] classes. They’re able to relax, and when they relax, they have a better labor and delivery, less complications,” he says.

Afeke identifies the adverse effects caused by the panic she felt during her first labor. “I was so scared, and when you’re scared, you become so rigid, so tense, so that makes the cervix not dilate.”

She now knows: “When you’re relaxed and calm, the labor comes more easily for you…it even helps minimize the pain, the joy you have knowing that you are bringing forth the baby. It can be a really nice experience.”

When women become more educated, they can take greater control of their health and their lives.

As Okra bolsters Eve’s Foundation with additional support, she is determined to help Ghanaian women exercise their right to accessible health education. “Eve’s Foundation wants to be a voice for these women, an advocate,” she proclaims.

Witnessing the hospital hallways crammed with worried women encourages Okra to keep fighting. She says, “We simply have to give women the confidence and trust that they were made to give birth.”



INITIATIVE COMBATING MATERNAL MORTALITY PRESENTS OBSTACLES

By Annie Robinson

ACCRA, Ghana – The nation-wide expansion last month of Ghana’s Health Insurance Policy, the government’s plan to help reduce maternal mortality, may increase risks to mothers’ health.

Since July, all Ghanaian women can access free maternal healthcare in government facilities from pregnancy through one-year post-partum.

Almost 51,000 women have already registered, according to the National Health Insurance Authority.

A 2007 Ghana Medical Journal report assesses the initial free maternal healthcare policy launched in 2003 in Ghana’s four poorest regions. It concludes: “Even if fee exemption leads to women with complications arriving in hospital earlier, the poor care they receive in hospital causes many avoidable deaths.”

The largest problem is a shortage of staff. There is just one trained midwife per 1,510 Ghanaians and one doctor per 17,733, according to the UN.

“What is the point of free services when there are not enough hospital attendants available? None!” says Florence Okra, a public health nurse and midwife.

Another problem is the government’s unwillingness to recognize the importance of midwives.

Although the Ghana Medical Journal “…assessed midwifery care as superior to that of doctors,” the insurance policy does not guarantee coverage of private midwifery services.

The Ghana Registered Midwives Association calculates 82% of midwives work in the private sector with just 18% positioned in public facilities.

Maternity homes, which offer women comprehensive, continual care from community midwives, initially lost clients.

“It looks like now…I have coverage. So some women are coming back,” says midwife Alberta Markham-Segbafah, who runs Amando Maternity Home in East Legon. “Nonetheless, our side of midwifery is not being encouraged.”

With the Health Ministry’s declaration in April that maternal mortality is a national emergency, midwives like Okra and Markham-Segbafah hold out hope that skilled help will eventually be available to all women in need.



A PORTRAIT OF FLORENCE OKRA

By Annie Robinson

ACCRA, Ghana - Propped up crookedly like a Raggedy Ann doll, Florence Okra gazes down at the IV threaded into her left arm. Usually an HIV counselor at Accra's Police Hospital, Okra seems out of place in its dingy female ward, where she is recovering from malaria.

Okra knows hardship well. A single mother of two sons, she never received a pesweh of support from her ex-husband who abandoned them during her second pregnancy. She earns just $300/month to support her boys, elderly father and two adopted orphans.

Her sparse one-bedroom apartment in the decrepit Police Barracks has not had running water for months. Every evening Okra unfurls a makeshift mattress for herself over a thin red rug on the living room floor.

Despite material impoverishment, Okra possesses fierce humanitarian commitment. "I don't have a car, nice clothes, I'm not called a successful woman – but I've helped a lot of people," Okra humbly acknowledges.

Foremost on her agenda: educating women and men about reproductive health, particularly pregnancy and childbirth. In 2000 her ambition engendered the NGO Eve’s Foundation. “I had the enthusiasm, so it began as a free service,” Okra recounts. She soon found herself broke from supporting the foundation alone, sleeping on an empty stomach.

Okra’s need to charge for the classes coupled with cultural resistance to health education means that now few women attend classes. “No one knows we need childbirth education, or that it exists,” notes Okra.

Yet Okra holds out hope for the foundation’s resurgence. She wants to leave her hospital job: “My interest is in the foundation; I’m being wasted.”

Trapped in her job, fatigued, broke, and now ill, she admits: “My heart bleeds; I feel sometimes like giving up.”

She wipes the tears from her round cheeks and releases a sigh. The doctor, hours delayed administering her meds, is missing. Though blisters inflame her upper lip, she breaks into a gap-toothed grin, and waits.