Labor analgesia in low-income countries: Experience from Ghana

"We demonstrated that spinal labor analgesia can be provided in a low-resource setting with the development of appropriate protocols, staff education, and the availability of a few basic drugs," write Dr. Adeyami J. Olufolabi of Duke University Hospital and colleagues. They describe their "achievements and obstacles" in working to implement an effective labor analgesia service at a busy hospital in Accra, Ghana.

Spinal Obstetric Anesthesia in Ghana: Lessons and Challenges

The paper describes the activities and outcomes of a program to provide training and support to improve obstetric anesthesia in the maternity unit of a regional referral hospital in Accra, serving mainly women with high-risk pregnancies. The program was developed by Kybele, Inc., a nonprofit humanitarian organization that works to improve maternal and newborn care in low-income countries.

In initial visits, teams of medical volunteers found "generally adequate" supplies of anesthetic drugs at the study hospital. However, they also found problems related to understanding and appropriate use of pain control during labor. In particular, cesarean section was usually performed with general (inhaled) anesthesia, which carries a significantly higher risk of complications compared to neuraxial (spinal or epidural) anesthesia.

Anesthesia leaders offered practical training in spinal anesthesia for cesarean delivery. This included the development of a single-shot spinal labor analgesia technique using "pencil-point" needles -- a simpler and safer alternative to more complex epidural analgesia techniques. Hospital personnel were also offered training in preanesthetic evaluation, patient assessment, and handling problems such as blood pressure drops and inadequate anesthesia.

Over the first three years of the program, use of spinal anesthesia for cesarean section increased dramatically: from six percent to over 89 percent of procedures. In subsequent years, spinal anesthesia rates rose to 95 percent or higher. These gains were sustained even as the annual number of cesarean deliveries more than doubled.

The collaboration yielded other improvements as well, including a preanesthesia clinic, recruitment of additional anesthesia staff, initiation of a nurse anesthesia training program, and creation of an obstetric and postanesthesia care unit. Over five years, overall maternal mortality rate at the study hospital decreased by 23 percent.

Spinal anesthesia also saved considerable resources, compared to general anesthesia. In addition to the availability of safe and effective anesthesia, mothers appreciated being able to remain conscious during cesarean section, since it allowed them to find out the baby's sex immediately after delivery.

The labor analgesia program was successful due to support from obstetric and nursing staff as well as hospital administrators, with "concerted and sustained advocacy efforts at individual and departmental levels," the researchers write. They also encountered some challenges to the program's sustainability -- especially related to manpower, cultural, and logistical constraints.

"Anesthesia providers bring a unique set of skills to the care of high-risk obstetric patients, well-recognized in high-resource countries," Dr. Olufolabi and coauthors conclude. "We must work to overcome barriers that prevent broader roles for involvement of anesthesia providers in maternal and neonatal care in low-resource countries."