CHAPTER 5: SUMMARY OF MAIN RESULTS AND LESSONS LEARNT
5.3.2 Transfusion service in Bansang hospital
One of the factors responsible for the dramatic reduction in maternal mortality in developed countries has been the readily availability of blood for obstetric emergencies. In developing countries were the majority of maternal deaths occur, only few have a well-organized transfusion services (82).
In this study anemia was identified as a very important cause of death (12 out of 42); obstetrical hemorrhage was also high among the cases (10 out of 42) and a significant proportion of the cases had undergone a caesarean section (5 out of 42). What is common among these cases (27 out of 42) is that all needed blood for transfusion. Some were transfused and others not. Even among those transfused delay in receiving prompt and adequate blood was an issue. Bansang hospital like many peripheral hospitals in developing countries blood is not readily available. During the course of data collection for this study I effort to explore blood transfusion services in the hospital. I interviewed health care providers including nurses, midwives, doctors and laboratory personnel. Also interviewed were pregnant, laboring or newly delivered women who needed blood, so also their escorts or relatives were interviewed. I did also utilized observation methods to see issues surrounding transfusion services in the hospital. Factors identified to have contributed to the problems in the transfusion services particularly shortages of blood for transfusion are:
Reluctance for blood donation: People in these two divisions are generally reluctant to donate blood even to a relative or a loved one. Donating blood is viewed dangerous. It is believed to undermine the health of the donor. There is a particular local tribe that is very reluctant to donate blood so do everything to evade it.
High incidence of anemia: The proportion of patients particularly women reporting to the hospital needing blood transfusion is overwhelming compared to the availability of blood in the hospital. In other words the demand is higher than the supply so leading to disequilibrium. Anemia is very common in the area especially among women of reproductive age. The possible reasons for this high incidence of
anemia may be due to the high fertility rate, too many, too frequent and too early pregnancies;
inadequate nutrition, and the endemic malaria situation in the area.
Low male involvement: In the Gambia patients going to health institutions for care are generally escorted by older women. This is more common in the rural areas and particularly for maternity cases as pregnancy and childbirth are regarded entirely a female entity. This strains the transfusion services at the hospital. These women escorts are unfit to donate blood and very few males escort patients to a health facility.
However, the shortage of blood at Bansang hospital cannot be entirely blamed on the above factors.
Certain operational issues in the hospital may be the main contributing factors and should be the speaking point. The World Health Assembly (83) endorsed the application of the principle of voluntary unremunerated blood donation in all communities. Fleming (82) argued in favor of unremunerated blood donation for four reasons that it increases the supply of blood because society will donate as being a donor will be prestigious; the donated blood will be safer for the recipient as potential donors who realize that they have risk behavior are generally willing to exclude themselves unlike the paid blood donors who will conceal their sexual risk behavior rather than forfeit payment; paid blood donors are at higher risk of developing anemia themselves as they may be poorly nourished; and fourthly unremunerated blood donation is cheaper for both health service users and health institutions.
In Bansang hospital a passive strategy in the management of the transfusion services is adopted as the function of ensuring blood availability is relegated to the patients or their relatives. “Directed” blood donation where blood is collected, usually from relatives, to designated patients; “replacement” donation where relatives of patients who received transfusion are asked to repay the units of blood to the bank;
and “remunerated”, “professional” or “commercialized” donation in which blood is donated on cash and carry basis. Relatives of the patient pay the cost of the blood donated. All these are practiced and encouraged in the hospital. Voluntary blood donation is virtually non-existent in Bansang hospital.
Unlike the other public hospitals (RVH and AFPRC hospitals) where a more active and aggressive approach are being employed in assuring blood availability. New donors are recruited and at the same time maintaining current donors. In these hospitals “commercialized” blood donations are not entertain.
In Bansang hospital there is no systematic recruitment of blood donors so consequently commercial blood donation is the predominant way blood is acquired.
From the testimonies in the data collected the following are constant issues mentioned with regards to blood and blood transfusion.
Relatives or escorts of patients needing blood “told” by the staff in the ward (nurses, midwives or doctors) to find blood for “their patient”;
When relatives or escorts go to the laboratory for blood they are reportedly told blood was not available and that they should either donate or get a donor for “their patient”;
Laboratory staff allegedly said to be the ones who identify professional or paid donors;
Relatives mentioned that money for the blood is paid to the alleged donor but in some instances to the laboratory officer;
At times the number of blood units paid for was not made available to the individual patient it was designated;
Blood paid for and not used by the individual patient is demanded back by the relatives or alternatively the amount of money paid requested;
Unused blood by the designated patient is at times marketed to relatives of other patients’ in need of blood by the relatives that bought it; and
Laboratory personnel accused by local communities of selling or reselling blood.
The above testimonies could be useful in addressing the transfusion services at Bansang hospital.