German Development Cooperation draws on regional expertise to reduce maternal deaths in Kyrgyzstan and Tajikistan by building the clinical skills of anesthesiologists and intensive care doctors
Medical teams in maternity hospitals often face life and death situations during deliveries. Yet in Kyrgyzstan and Tajikistan, anesthesiologists and intensive care doctors have not been trained in methods which their colleagues in other countries regularly use to save the lives of mothers and their babies. German Development Cooperation is addressing this gap by building the clinical skills of anesthesiologists and intensive care doctors – and by promoting new evidence-based protocols to guide medical teams in the management of obstetric emergencies.
Difficult and dangerous conditions for women with complicated pregnancies
Damira Seksenbaeva has two decades of experience working as an obstetrician in her native Kyrgyzstan and has seen her fair share of complicated deliveries. She knows firsthand that if the right steps are not taken quickly, women and their babies can die or become disabled as a result of problems arising before, during and after childbirth. She also knows how challenging the conditions in Kyrgyz maternity hospitals have traditionally been – and the many reasons why it has been difficult to ensure rapid and effective emergency obstetric care.
One of the main problems, according to Seksenbaeva, has been the absence of standards and protocols for obstetric care: in emergency situations, it wasn’t clear what measures should be taken and by whom. Members of the medical team, each drawing upon their own narrow training in obstetrics, anesthesiology or intensive care, would do what they could to manage complications, but they often worked sequentially, rather than in concert. Shortages of essential drugs and equipment compounded the challenges.
‘It was difficult to work in this environment,’ Seksenbaeva explains, ‘and sometimes women died. At times I couldn’t even explain to myself or to others why a complication had arisen and why I wasn’t able to help my patients.’
The beginnings of a small revolution
Over the past two years, however, Seksenbaeva has witnessed the beginnings of a small revolution in her field. Although there is still a long way to go, she believes that enormous progress has been made in the provision of emergency obstetric care in Kyrgyzstan – and that German Development Cooperation has played an important role in this. On behalf of the Federal Ministry for Economic Cooperation and Development (BMZ), the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH has been supporting measures through the Health in Central Asia programme to develop evidence-based clinical guidelines on emergency obstetric care for anesthesiologists and intensive care doctors and to build the expertise of multidisciplinary medical teams to implement these guidelines in their daily work.
This new approach is already yielding results. Recently, Seksenbaeva attended a delivery in which the mother started hemorrhaging after the birth. This was a situation with potentially deadly consequences: postpartum hemorrhaging is the leading direct cause of maternal death in low-income countries. In accordance with the clinical protocols now in place at the hospital, she immediately called for help from the other doctors, including an anesthesiologist, and began following the recommended staged approach to treating postpartum hemorrhaging, including the administration of uterotonic drugs. Working at her side, an intensive care doctor responded to the blood loss by replenishing the woman’s fluids and monitored her condition continuously. Working as a team, they successfully managed the emergency and saved the mother’s life.
Seksenbaeva thinks back to the earlier years of her career. ‘Previously, in similar situations, we would have used blood transfusions and carried out a hysterectomy in order to save her life,’ she said. ‘In this case we saved her life and gave her the possibility to have more children in the future.’ By following the clinical guidelines and working in a coordinated manner, a potentially fatal outcome was averted. ‘Afterwards,’ she adds with satisfaction, ‘the patient’s gratitude knew no bounds.’
Too many women don’t get the antenatal and obstetric care they need
According to the World Health Organization, Kyrgyzstan has the highest maternal mortality ratio in Central Asia – 75 deaths per 100,000 live births in 2013. In Tajikistan, the figure stands at 44 deaths per 100,000 live births. In both countries, a lack of antenatal care and low levels of awareness about pregnancy-related danger signs are part of the problem. Female migrant labourers, whose numbers are on the rise, often do not have access to services while pregnant and other women, particularly in rural areas, are discouraged by their families from visiting clinics. As a result, too many pregnant women are first seen by medical professionals when they go into labour or when a complication has already reached a critical stage.
Poverty, malnutrition, and women’s low overall health status compound these challenges. ‘We are witnessing high rates of anaemia in pregnant women, which drastically increases their risk for obstetric bleeding,’ notes Nazgul Karabaeva, head of the intensive care unit at the Issyk-Kul Regional Hospital in Kyrgyzstan. ‘Many of our patients also suffer from hypertension and lots of women have early deliveries at 28 weeks gestation.’
Although the medical teams at maternity hospitals regularly see women with complicated pregnancies and deliveries, they are generally not well equipped to provide them with good-quality care. Medical training in both countries favours theoretical over practical learning and, as a result, most physicians do not have the right skills to help women who experience serious complications before, during or after childbirth. No specialised training is available for anaesthesiologists and intensive care doctors who work in the field of obstetrics and, because evidence-based protocols which reflect current international standards for obstetric care have been missing, they have continued to rely on traditional forms of emergency care taught during the Soviet period (i.e. heavy reliance on drugs, infusions, blood transfusions and surgeries). These approaches are more invasive, and have more detrimental consequences for patients, than those used by their peers in other countries.
An innovative way to address the gap
In 2009 the Kyrgyz Ministry of Health began to systematically analyse causes of maternal mortality in order to better target its response. It found that more than half of maternal deaths were preventable and that some 80 per cent were due to direct causes, including postpartum haemorrhage, hypertensive disorders, postpartum infections (mainly sepsis) and obstructed labour. The inadequate and belated provision of anesthesia and intensive care was identified as a major contributing factor.
While development partners, including the United Nations Population Fund (UNFPA) and the United States Agency for International Development (USAID), had begun working with Kyrgyz obstetricians to improve their skills in handling complicated deliveries, little if any attention was being paid to other types of specialists, such as anesthesiologists and intensive care doctors, who need to work side-by-side with obstetricians on complex cases.
GIZ saw an innovative way to address this gap. Through the Health in Central Asia programme, which it implements in Kyrgyzstan, Tajikistan and Uzbekistan, GIZ was familiar with the successful nationwide effort led by UNFPA in Uzbekistan between 2008 and 2012 to build the skills of more than 600 anesthesiologists and intensive care doctors countrywide. It recognised an opportunity to bring relevant expertise – from a nearby country with a shared history, culture and language and similar health system challenges – to bear on the situation in Kyrgyzstan and Tajikistan. With agreement from the Ministries of Health in all three countries, GIZ engaged the services of specialists from the National Perinatal Centre in Uzbekistan to assess the main clinical and organisational challenges in the delivery of emergency obstetric services in Kyrgyzstan and Tajikistan and to help develop an action plan for addressing them.
The findings were clear, if also ambitious: in order to reduce the number of women and infants dying as a result of complicated deliveries, clinical guidelines aligned with international standards needed to be developed and teams of specialists from different backgrounds needed to be trained to work together to implement their contents.
Developing clinical guidelines
In cooperation with the Kyrgyz and Tajik Ministries of Health, GIZ convened a group of experts from Kyrgyzstan, Lithuania, Tajikistan and Uzbekistan who took on the task of developing clinical protocols on emergency obstetric care in line with the principles of evidence-based medicine, using the recently-revised protocols from Uzbekistan as a guide. The protocols outline standards of care and set out the clinical steps which should be followed by medical teams when treating women with hypertensive disorders, sepsis, or obstetric bleeding. They also outline the use of spinal anesthesia for Cesarean and natural births, and for mitigating severe eclampsia. Following two years of painstaking work, the team – with support from GIZ and international experts – secured technical approval of the protocols from the ministries in both countries.
In parallel, the expert working group developed a curriculum linked to the clinical protocols which has subsequently been used to train 150 anesthesiologists, intensive care doctors and obstetricians from hospitals across Kyrgyzstan and Tajikistan. More than 20 five-day sessions were hosted at the main perinatal hospitals in Bishkek and Dushanbe, led by international experts from Lithuania and Uzbekistan. Multidisciplinary teams of clinicians from the same health facility were invited to attend trainings together.
Building practical skills…
The training programme supported by GIZ was distinctive in format. ‘More than half of the training was dedicated to developing practical skills,’ recalled Damira Seksenbaeva, the Kyrgyz obstetrician. ‘It focused on things like using spinal anesthesia in the operating room and solving specific clinical situations. This is the first time such an approach has been used in our country.’
Cholpon Asambaeva, the team leader for GIZ in Kyrgyzstan, believes that the combination of theoretical and practical training was very important. ‘Some participants didn’t want to admit that they didn’t know how to do certain procedures, or were afraid of making mistakes,’ she said. ‘But the trainers were sensitive to this and found ways to get them practicing new techniques.’
…and focusing on teamwork
Another distinctive element was the decision not to train individual doctors, but teams of personnel who work together on a regular basis. For Dinara Mambetalieva, the head of intensive care at the Perinatal Centre in Bishkek, the value of the training lay not only in the exposure to international standards, but also in the focus on teamwork. Participants learned, through analyses of ‘near miss cases’ of obstetric hemorrhaging, how women’s lives can be saved when a multidisciplinary team works as one.
‘When critical situations develop at maternity hospitals, the atmosphere can be chaotic,’ she explains. ‘If a mother has to be resuscitated, the right decisions must be taken and the right interventions carried out. The medical team must work in a coordinated manner.’ When obstetricians, anesthesiologists and intensive care doctors don’t communicate clearly with one another, or aren’t working together seamlessly, complicated situations can turn into full-blown crises – and sometimes result in women dying.
The value of the trainings was enormous, she continues. ‘If before I had a lot of thoughts about how to better organise the work in my department, now I have real instruments that I can use to do it. We’ve managed to create a single team, joined together by common goals, in our workplace.’
Changing clinical practices
Almaz Asymbaev is an anesthesiologist and intensive care doctor who works at the regional hospital in Talas, a city in Kyrgyzstan’s mountainous north. More than 2,700 babies were delivered at the Talas hospital in 2013, approximately one tenth of them by Cesarean section.
Prior to the GIZ-supported programme, Asymbaev recalls, there were no guidelines or standards governing the use of regional anesthesia for childbirth at his hospital and general anesthesia was used in the majority of cases. Epidural anesthesia was used for a small proportion of natural and Cesarean deliveries, but complications often arose. Anesthesiologists and pregnant women alike were somewhat fearful about its use, despite its many advantages for both mothers and babies. Short-acting spinal anesthesia, which is appropriate for most Cesarean deliveries, was never used.
Today, the situation looks significantly different. With support from GIZ, clinicians from Talas hospital have been trained in the new emergency obstetric care protocols, including practical sessions at the Perinatal Centre in Bishkek which focused on the use of epidural and spinal anesthesia in obstetric care. From 2013 to 2014 the proportion of Cesarean births conducted under regional anesthesia at the hospital tripled, from 12 to 36 per cent. While general anesthesia is still used in the majority of births, anesthesiologists are increasingly confident to use regional anesthesia, including spinals.
Asymbaev rattles off a list of perceived benefits: ‘The obstetricians and neonatologists believe that the increased use of regional anesthesia has improved Apgar scores, reduced the need for Naxalone to counter the depression of infants’ respiratory systems, and greatly reduced the volume of blood lost during procedures. The anesthesiologists appreciate the ease of implementing spinal anesthesia,’ he continues, ‘and see that there are fewer problems with post-operative pain.’ Compared to general anesthesia, they worry less about operating on women who may have eaten recently. Moreover, the experience for women is significantly better – they are awake and hear the baby’s cries, which is very important for them psychologically.
The changes have not all come easily, however. At the beginning, the hospital administration was not fully supportive of the new protocols and certain physicians resisted changing their established ways. As more clinical staff from the hospital were trained in the new standards, and were exposed to the experiences of international experts in their fields, support began to build. More and more obstetricians at the hospital now actively request that anesthesiologists use spinal anesthesia. In addition, the hospital is becoming an important resource for health facilities in outlying areas, with staff like Asymbaev conducting seminars and trainings for colleagues from across the region.
Consolidating regional expertise
This focus on building the local and regional capacity of anesthesiologists, intensive care doctors and obstetricians has been at the centre of the efforts supported by GIZ. From among the initial 150 medical personnel who were trained through the programme, 15 – including Damira Seksenbaeva, Dinara Mambetalieva and Almaz Asymbaev – were selected to become master trainers. This cohort of ‘multipliers’ is now qualified to provide other obstetricians, anesthesiologists and intensive care doctors with practical on-the-job training on effective emergency obstetric care.
At the same time, the training curriculum is being integrated into the continuing medical education systems in both Kyrgyzstan and Tajikistan, to ensure that new generations of anesthesiologists and intensive care doctors who complete their training as generalists will have the opportunity to gain more specialist knowledge related to obstetric cases.
The GIZ-implemented programme has also helped to consolidate regional expertise in emergency obstetric care through its contributions to the Perinatal Care Forum in Bishkek in June 2014, which focused on efforts to accelerate progress on Millennium Development Goals targets for child and maternal health. Forum participants from Kyrgyzstan, Tajikistan and Uzbekistan enthusiastically took part in a series of practical master classes led by German, Lithuanian and Uzbek specialists which GIZ organised during the second day of the event. The programme has also supported study tours to Lithuania and Uzbekistan to introduce Kyrgyz and Tajik clinicians to approaches to emergency obstetric care in other settings.
The measures undertaken by German Development Cooperation thus far demonstrate the promise of drawing on regional expertise and working across narrow disciplines to address engrained health problems. ‘I’m very proud of the role that our programme has played in getting the ball rolling,’ says Evi-Kornelia Gruber, the director of the Health in Central Asia programme. She notes with satisfaction that the Ministries of Health and professional medical associations in both Kyrgyzstan and Tajikistan took on responsibility for developing the new clinical guidelines, integrating them into national policies and medical education systems, and supporting their introduction into routine clinical practice by training medical teams.
This year, the Health in Central Asia programme intends to support the establishment of a training and resource centre for continuous medical education in emergency obstetric care and to advise the Ministry of Health in Kyrgyzstan on a national mentoring system for anesthesiologists and intensive care doctors. While these and other measures will help to consolidate the changes already underway, momentum is slowly building in maternity hospitals across the two countries. ‘Many multidisciplinary medical teams tell us that they can see the advantages of the new protocols in their daily work – and that mothers’ experiences in delivery rooms are improving as well. I am confident that this “small revolution” will continue to grow,’ says Gruber.
By Karen Birdsall