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AFRICA: Shortage of Skills for Reproductive Health

NAIROBI, Aug 13 2010 (IPS) - Dr Geoffrey Kasembeli says he worked almost seven years without a day off: that’s how severe the shortage of obstetricians and gynaecologists in Kenya is. A similar situation prevails across the continent, a symptom of the weakness of reproductive health care in Africa.

Until the end of 2009, Paul Mitei was the only doctor specialising in reproductive health at the Kisumu Provincial Hospital, handling all referrals for an entire province. A second gynaecologist has joined him at the hospital – working pro bono – but he says the workload is still very heavy.

“Wow, I am not sure how many patients I see in a day, after a while I lose count,” he told IPS. “They are simply too many, almost overwhelming.

“I used to literally go for several months without being off-duty because I was the only gynaecologist in the hospital. While other doctors and the mid-wives can help, there are essential specialised services that must be attended to by a gynaecologist, so this meant I had to be at the hospital for long hours and days on end.”

Across Africa, there is an acute shortage of specialists in women’s reproductive health.

Skills needed

A global countdown report released in early June shows that a lack of skilled attendants at birth accounts for two million preventable maternal deaths, stillbirths and newborn deaths each year. The report states there is a severe shortage of midwives – worldwide, an estimated 700,000 new midwives and other trained providers are needed in order to provide skilled childbirth care to all women who need it.

In Africa, an additional 1.5 million health workers are said to be needed according to the report. 

Professor Joseph Karanja of the University of Nairobi belongs to a regional association of obstetricians and gynaecologists in Eastern and Southern Africa. He says Uganda and Tanzania each have around 200 such specialists for populations of 33 and 45 million respectively. Zambia has 50 for its 13 million people. Lesotho can boast of only two or three for its nearly two million people.

Namibia’s medical directory lists 13 gynaecologists. In Oshakati, 750 kilometres from the Namibian capital Windhoek, Dr Innocent Mavetera can identify with his Kenyan counterparts.

“We are not enough, that’s why there is now a situation where general practitioners are performing caesareans, taking advantage of the critical shortage, fuelling chances of complications during the operation,” he said. “We are stretched, and are always fully booked. I am already fully booked until the end of October and this disadvantages patients.”

Kenya has only 340 registered gynaecologists serving a population of 38 million. Karanja says the shortage of these highly-qualified personnel is exacerbated by the uneven distribution of the few who are available.

“With so few specialists, it means women in rural and peri-urban areas have no access to a gynaecologist because the few who are available are concentrated in urban areas and they are expensive,” Karanja says.

Only a tiny proportion of African women have access to skilled medical care for a wide range of reproductive health issues including cervical and uterine cancer, problems with fertility, or reconstructive surgery for conditions like fistula.

The shortage also impacts on reducing maternal and infant mortality rates – in most countries, the women most likely to develop complications and need high-level intervention are also those unlikely to have timely access to such care.

In Windhoek, Dr E W Lisse told IPS, “We don’t have enough gynaecologists in the country, especially at state hospitals. In cases of emergencies, patients have to be transferred long distances to get treatment. The impact is mostly on the indigenous population who also don’t have medical aid and can’t afford gynaecologists in private practice.”

Where clinical officers, midwives and nurses are unable to offer the necessary care, they have to refer women to higher-level facilities. Time is of essence, for example when a labouring or post-partum woman is haemorrhaging, but too many never make it to a distant referral hospital.

The hospitals themselves are typically understaffed at all levels – Kenya’s health ministry estimates that 17,000 more nurses are needed in that country – and there is typically just one resident obstetrician/gynaecologist.

“In cases of emergency, you need to have providers who can quickly spot danger signs and know exactly how to react. Some of the cases that are brought to the referral hospital often end in death but had the right decision been made from the on-set, the life of the woman would have been saved,” Mitei says.

The shortage of healthcare workers is a global phenomenon. While wealthy Europe and the U.S. can afford to lure staff with lucrative pay, African countries often cannot compete and lose the limited numbers of trained personnel. Those willing to work for government hospitals such as Mitei and Kasembeli face long hours for much lower pay than is offered in the West or the private sector.

If governments are serious about achieving development goals on maternal mortality and women’s reproductive health, they will have to find ways to improve the numbers and distribution of skills in the public health service.

Karanja agrees with the view of the Kenya Obstetrical and Gynaecological Society that government will need to step up its effort to train clinical officers and midwives so they are able to perform many procedures that were previously the preserve of ob/gyns to improve reproductive healthcare.

*Patience Nyangove in Windhoek contributed to this report.

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