I saw an article recently in the British press about the high under five child mortality rate of the UK (www.theguardian.com/society/2014/may/02/uk-child-death-rate-western-europe-health). It caused me to reflect on the differences between child death in the UK and Ethiopia. The UK under five child mortality rate in 2012 was 4.8 per 1000 (30th in the world). This is high compared to other western European countries (Norway’s rate is 2.8 per 1000) and I agree needs to be improved. However for other countries, like Ethiopia, this rate is something to aim for. In 2012 the under five mortality rate in Ethiopia was 68.3 per 1000 (156th in the world). The rate in Ethiopia has fallen dramatically from 204 per 1000 in 1990. A child mortality rate of less than 5 per 1000 is just a dream currently for health professionals working in Ethiopia and other countries round the world.
It is a tragedy when any child dies anywhere in the world. The aim should always be to reduce the number of children dying and examine the causes of deaths so action can be taken. The lower the child mortality rate gets though the more difficult it is to affect it. Ethiopia has taken significant action to try to reduce the under five mortality rate and meet the Millennium Development Goal to reduce the under five mortality by two thirds. It was announced in September last year, not long after I arrived in the country, that the MDG for under five mortality had been achieved. This is fantastic as it makes Ethiopia one of only a handful of countries currently to achieve this MDG.
Behind the headline figures is another story though. Ethiopia is a federation of 9 regions and 2 city administrations. The rate of child mortality varies considerably between each region with some still having an under five mortality rate as high as 169 per 1000 in 2011, while others have a rate as low as 53 per 1000. You also have to look at the age under five of the child when the death occurs. The rate of neonatal deaths is still high. Although child mortality decreased rapidly, neonatal mortality (death in the first month after birth) has not decreased as rapidly. The neonatal mortality rate was 3 per 1000 in the UK in 2012 (34th in the world) compared to 29 per 1000 in Ethiopia (168th in the world). In comparison to the under five mortality rate as a whole the neonatal mortality rate in Ethiopia has decreased by less than half from 54.2 per 1000 in 1990.
Death is more common here but there is always sadness when a child dies. Families mourn their children no matter how old the child is (newborn or older). Just because families often have many children doesn’t meant that life is seen as cheap or not as important because they are only children. It is particularly hard for me when a child dies who I feel that if they had been in the UK I could have done more to save the child’s life.
Events around a death in hospital follow a different pattern here. In the UK resuscitation attempts are prolonged with the family present and kept informed throughout. I found when I arrived that resuscitation was not always attempted for babies and children, although this has improved since my arrival with nurses now attempting resuscitation even if there is no doctor present. The family is often in a different part of the ward and do not always want to be present with the child. After the child dies they are wrapped in white clothes and given to the family for burial. Usually the male relatives will leave the ward with the child and the shovel and pick axe that are kept on the ward. After the child has been buried they return the tools and the family will leave to mourn in private.
There is still plenty to do in Ethiopia that will affect the child mortality rate. Reducing the neonatal mortality rate is a major part of the challenge and one of the reasons that I am working here in Ethiopia is with the aim of establishing a neonatal unit here at Axum St Mary Hospital. The neonatal deaths here occur mainly due to infection or prematurity and low birth weight. Basic care can help a lot of the babies who currently die. Keeping preterm babies warm, making sure they get the right amount of feed to gain weight and supporting their breathing can save a lot of babies who otherwise wouldn’t survive. For infection it is about recognizing a child is sick and starting antibiotics early. Stopping some traditional practices (uvulectomies and use of traditional medicine) that often lead to infection would also help. Education of mothers and families is essential.
Through improving nursing care, giving guidelines for neonatal care, training staff in newborn resuscitation and care, creating a neonatal unit with the equipment needed we hope to help to reduce the neonatal mortality rate here in this small corner of Ethiopia.
It’s only Monday and already I feel frustrated and like I’m banging my head against a brick wall. Here is just a sample of two stories from the day.
Last week a 30 week preterm baby was admitted after being born in a local health centre. In contrast to a 31 week baby who was admitted after birth a few weeks ago and stayed hypothermic with respiratory distress until she sadly died at the age of 3 days more resources were available for his care. He was placed under the radiant warmer (to make sure he was kept warm) and started on bubble CPAP (a type of breathing support which I had made following diagrams found on the internet from oxygen tubing and a plastic bottle filled with water connected to an oxygen concentrator). We also started aminophylline to stimulate his breathing. In the UK intravenous caffeine would normally be used (no you can’t get it unless you’re a preterm baby!) but that is not available here. The baby had been doing well and is breathing for himself without any support and tolerating milk feeds down a nasogastric tube. When we checked on Saturday he had started to get a bit jaundiced (not uncommon in preterm babies). Despite trying there were no lamps working to attempt phototherapy (a proper phototherapy machine is a dream in the future) so we did our best by trying to turn him towards the window to catch some sunlight. Unfortunately on Monday despite everything else going well the jaundice was significantly worse. The machine is broken to measure the actual level but the baby was glowing so severely jaundiced! If the jaundice level gets too high there is a risk of brain damage. I asked and referred the baby to the nearest tertiary hospital that could provide treatment to try and prevent this. The hospital is in Mekelle, a 6-8 hour drive away, and the mother had problems getting transport to get there.
Next to that little boy is another girl who was preterm also but about 33-34 weeks. She has an imperforate anus and a fistula so stool was coming out the vagina. Her abdomen had been getting bigger and bigger as there was no outlet. The surgeon at the hospital decided he couldn’t operate after seeing the baby at the weekend. If an operation isn’t done urgently the baby will die. It took me all day asking different people to find out which hospital I could refer the hospital to, the one in Mekelle or straight to one in the capital Addis. Finally after writing the referral at midday at 4pm I found I could refer the baby to Mekelle.
Despite asking I was told there was no hospital transport available for the babies due to no fuel. It was up to the family to make the journey themselves if they could to Mekelle and the hospital there. Discussions and counseling were still happening when I left the ward that evening. When you know that treatment is available and can’t break through all of the barriers to get the patients to the treatment it’s so hard and upsetting when you know a poor outcome could be prevented by early treatment.
Today I went in to the ward and found that both families had left together this morning at 5am to make the journey to Mekelle. I will be crossing my fingers and praying for them both.