Can "Tele-health" Cut Maternal Mortality in Zambia?

Zambia is unlikely to meet the Millennium Development Goal (MDG) on maternal health as more than 700 women die each year from pregnancy related complications. This is cording to former Health Minister Angela Cifire, who bemoans that Zambia's maternal health is one of the highest in the sub-Saharan Africa region -- with 720 of 1,000 live births resulting in death.

In the 2007 MDG report, Cifire observes that unlike the latest Hollywood trend, in which celebrities give birth in an exclusive labor ward especially furnished for the babies' arrival with video cameras ready to put everything on record and more doctors than necessary at one's disposal, labor is usually tormenting for most Zambian women -- especially those in rural areas.

Recently there has been an increase in cases of women even in urban areas delivering in non-conducive situations, thereby endangering their lives. Most of these women die due to lack of skilled labor, excessive bleeding, as well as lack of donated blood. The country must grapple with the challenges of meeting the millennium development goal on reducing maternal mortality by the year 2015. Cifire called for collective action to save hundreds of mothers who die from pregnancy related complications.

Women for Change Executive Director Emily Sikazwe says she was saddened by the  high maternal mortality rate in the country. World Health Organization Country Representative Stella Anyangwe said it was sad that the just-launched Vision 2030 does not address maternal health and primary health care like it does on HIV/AIDS.

In 2001-2002, 77.2 per cent of the women who had a non-institutional delivery did not receive postnatal check-up. Women in rural areas (81 percent) were discharged before receiving the postnatal check-up, compared with those in urban (53 percent) who did not receive the postnatal care. Other reasons for increasing Maternal Mortality Ratio (MMR) include limited access to facilities due to few health facilities; long distance to facilities; lack of or costly transportation facilities; shortage of trained staff; attitude of some health staff; and poor quality of care (untrained staff and lack of surgical and medical supplies). Low postnatal care, prenatal complications, complicated deliveries, postpartum deaths from hemorrhage and infections and post abortion complications also contribute to increased maternal mortality rates. 

Maternal mortality increased from 649 deaths per 100,000 in 1996 to 729 deaths per 100,000 births during the period 2001 to 2002. According to the UNDP 2003 MDG report, the target for maternal mortality ratio in 2015 is 162. The critical indicators in maternal health include access to antenatal, delivery and postnatal care. A total of 95.7 per cent of the women in 2001-2002 received antenatal care; 93.4 per cent from a health professional and 2.3 per cent from a Traditional Birth Attendants (TBAs). 

The percentage of women receiving antenatal care from a health professional slightly decreased from 96 per cent in 1996 to the 93.4 per cent in 2001-2002 period. One contributing factor to high maternal ratio could be the increase in the number of women delivering at home. During the 2001-2002 ZDHS, 56 per cent of the women delivered at home and fewer of them, 44 percent, at a health facility. 

Medical persons are also attending slightly fewer deliveries, while the proportion of births attended by traditional birth attendants (TBAs) increased to the highest record in 2001-2002 since 1992. The proportion of women delivered by a medical person declined, from 51 per cent of births in 1992 to 47 per cent in 1996 and 44 per cent in 2001-2002. The proportion of women delivered by a relative or friend consequently, increased from 33 percent in 1992 to 41 per cent in 1996, though slightly declined to 38 per cent in 2001-2002. Postnatal care is important in detecting complications related to delivery.

Meanwhile, the use of information communication technologies (ICTs) in delivering care to pregnant women and newborns in Lusaka is on the verge of becoming easier and more efficient, thanks to the advent of Tele-health, which is simply the use of information technology to deliver health services and information from one location to another.

Collins Chinyama, former information technologist at the Central Board of Health, describes the concept of tele-medicine as a multimedia system using voice, video and data to deliver medical services remotely. "People may phone their doctors and prescriptions are done either by telephone or fax," he says.

But the new technology overcomes the limitations of the telephone and fax to ensure that patients are diagnosed from remote locations. Tele-medicine has its advantage and negative sides: though it meets government needs for bringing health care as close to the family as possible, the need for medical workers will also diminish. But it has the potential to bridge the gaps created by Africa's brain drain as health professionals seek greener pastures in developed nations. "There is need for tele-health in Africa because it has very few doctors and there are increasing health needs and staff constraints in most hospitals," says Chinyama.

Tele-health works by installing information technology such as digital cameras, camcorders, digital senders and other medical equipment in all health centers. Lusaka women and their babies are the first beneficiaries of new technology in health, with the establishment of an electronic prenatal record system.

It is fitting that this new technological adventure should start at the source of life: many of the basic needs in the care of pregnant women and newborns have largely been unmet in Zambia. This is despite the fact that inadequate resources can literally be a matter of life and death in the maternity situation. Zambia's maternal and infant mortality indicators are unacceptably high. United Nations statistics show a one in 14 lifetime risk of death in pregnancy for women. The just released demographic and health survey show that these statistics have not improved over the past five years, making this a high priority concern.

Customized software designed by doctors from Lusaka district, the University of Zambia Teaching Hospital (UTH) and the Central Board of Health (CBOH) will eventually replace the paper records currently in use. Computers in all Lusaka clinics that provide antenatal care will be linked with several wards at the teaching hospital through a high speed wireless network. Patient data will, therefore, be entered just once and not a dozen times. Whether or not a woman goes to the same clinic, the nurse attending her will be able to see all the relevant information about her without having to ask for it and re-entering it again.

Healthcare for pregnant women in Lusaka is a large and complex system. Nearly 50,000 deliveries take place in Lusaka district clinics and the teaching hospital. Most mothers make multiple antenatal and postnatal visits, and many of them go to several sites for health care. Benefiting groups will receive better care because clinicians will have more information and more time to focus on giving care.

Maureen Chitalu, a mother of three, says she hopes the use of information technology will also manage complicated cases. She explains: "I live in Mutendere, where I also go for my antenatal care. During my previous pregnancies, nurses kept on referring me to the UTH, where there are specialists, because I delivered by cesarean section last time I was pregnant. It was not easy. I had to spend a lot of money on transport and, in the process, wasted a lot of time. With the new system in place this should now be a thing of the past."

At one time, clinic staff at the teaching hospital could not find her records as they were never kept in an organized manner. But the tele-health project now means clinicians will be able to monitor and track patients, see their entire history at a glance and analyze the outcomes. Health care officials will be able to generate better information about the population.

Tele-health will also ensure security and confidentiality of patient information because it will be more difficult to gain access to patient data. Nurses and doctors will have to enter a password to see individual records. Although officials of the Central Board of Health and the district health management board will be able to see statistical information but only authorized clinicians will have access to personal patient information.

For now, an automated referral system is being written for Lusaka and it will be the first program that will be used in the computers. It is hoped to be introduced soon.

Chinyama explains that each clinician will receive an individual e-mail address. Telephones will be connected to the computers, allowing phone calls throughout the network and training manuals will be available on the computers. Free computer training is expected to take place through the end of 2003. It will include general computer knowledge, e-mail, filling out web-based forms, refereeing patients using the automated referral system and using Acrobat reader to access training manuals.

The benefits to clinical care will be that training materials will be easily available and there will be better communication between sites and automated checks on care quality. Voice Over Internet Protocol (VOIP) telephone will allow district health management board midwives to speak to teaching hospital midwives or doctors at any time. The health management board midwives will also be able to track their referred patients as the system will allow more accurate monitoring.

It is of great relevancy that Zambia applies emerging technologies to empower rural communities towards the attainment of the MDGs goals as this is the theme of the Africa Telecommunications Day which is observed on December 7 every year.