An obstetrician in Tanzania: 'The women who die in childbirth feel very close'
Dr Rhona Mahony, Master of the National Maternity Hospital, spent a week training healthcare workers in a remote part of Tanzania
Dr Rhona Mahony trains healthcare workers in Tanzania. Photograph: Robert Ngumbo
Saturday, August 16th
I have become a volunteer with Volunteer Services Overseas (VSO) and my first VSO opportunity is a short-term placement of one week in Tanzania. I am going out to teach the basic management of obstetric emergency to a range of healthcare workers in Mtwara, a remote area in southern Tanzania. In advance of an evening flight I do my best to pack usefully. The first thing to include is a plentiful supply of insect repellent. It is winter in Tanzania, and the evenings can be cool with the rains soon to start. An Irish summer comes to mind.
A few airports later, I am glad to arrive in Dar es Salaam. It’s a relatively small airport, pretty shabby and very busy. There is one luggage belt and, with no particular urgency, it shudders to a start and the cases rumble along. After a tense hour mine arrives with the newly acquired status of best friend.
Dar Es Salaam is a tale of many cities. A blend of African, Arabic, colonial and western expatriate influence, it is growing rapidly and is poised to become one of Africa’s leading cities. It had a shaky start under Tanzania’s first president, Julius Nyere, who promoted rural development at the expense of urban investment.
The resulting infrastructural deficits create challenges for today’s rapid growth but there is an infectious optimism in Dar Es Salaam. Skyscrapers, shopping malls, old colonial buildings, shanty huts and street markets jostle in a landscape that is happily chaotic and very busy. Roads suddenly become dirt tracks. The coastline sprawls with tourist opportunity.
Richly multicultural, people here are friendly and beautifully dressed. There is colour and energy everywhere. The city is buzzing but people are poor. Very poor.
Behind an economic growth rate of 7 per cent, and natural resources in plentiful supply, the conversation frequently turns to why Tanzania is poor. This question is likely to dominate next month’s elections. Rich resources and pervasive poverty is the African paradox. Women and children in Tanzania experience the consequence of this paradox acutely. The maternal mortality rate in Tanzania is 454 per 100,000 and the infant mortality rate is 31 per 1,000.
I spend the day at the VSO office, where I am briefed on the current situation. Tanzania has a population of about 50 million and the population is growing annually by 1 million, and half of the population are aged under 18. VSO has operated in Tanzania for more than 50 years and operates 18 projects in the key domains of education, health, livelihood and governance. These projects are strategic, with specific goals and measurable outcomes. The overarching aim is to build capacity and capability in local communities in a sustainable way. In Mtwara, the rural region I visit, a simple neonatal project “No baby left out” has reduced newborn mortality by 30 per cent and is now to be scaled up to encompass the two regions of Lindi and Mtwara.
The newborn strategy is based on simple measures, which include dedicated neonatal facilities, training in newborn resuscitation and care, and basic equipment. A simple newborn checklist assists staff in identifying sick infants.
Unfortunately, progress has been slower on the maternal side. Securing funding remains a major challenge and even then it can be difficult to find the right volunteers for each project.
It’s a 4am start. I am flying to Mtwara and then driving through the region to Masasi. I am accompanied by Aloys Ndamugoba, health programme officer with VSO. As we travel through Mtwara I bombard him with questions; he is endlessly patient and his answers are well informed.
We first stop at the regional hospital in Mtwara, which boasts the only obstetrician in the region of 1.2 million people and is a tertiary referral centre without the facilities. Here there are about 25 deliveries per day, which is similar to the number we deliver at the National Maternity Hospital. The Caesarean section rate is surprisingly high, at up to 20 per cent. To manage this there are two nurses and one medical officer. The hospital is tiny but calm, and frequently runs out of blood and basic medicines. When blood is unavailable, relatives sometimes donate.
We travel on to St Walburg’s in Nyengao. This is a faith-based hospital founded by German missionaries. It has a clear governance system, whereby the clinical director, director of nursing and hospital secretary report to a board chaired by the local bishop. It provides free services to mothers and under-fives, but is under severe financial strain as a result of a reduction in donations and reduced funding from the state in return for services. It is on a different scale but, as master of a voluntary hospital, this story resonates with me. The partnership with the state is somewhat strained.
In the afternoon we reach Mkomaindo District Hospital in Masasi. I spend the afternoon with Dr Moussa, a general practitioner who seems to run the entire hospital. Facilities at the hospital are basic. The labour ward is clean and two women are labouring as I visit. Another has delivered her baby and is receiving a blood transfusion following a post-partum haemorrhage. The next day a woman will be brought from an isolated village and she will die just after arrival because of haemorrhage related to a retained placenta. Nobody thought to deliver the placenta or to give her blood. Her death was easily preventable.
In the makeshift neonatal intensive care unit, twins are receiving phototherapy, and a baby is receiving oxygen via nasal prongs, while their mothers sit chatting on the floor. Bright blue mosquito nets are rolled above adult beds which are used as make shift cots. Wall tiles are chipped and the floor has seen better days in this tiny space as these fragile infants struggle for their first days.
This morning begins at a more civilised 7am. I meet the district medical officer, the regional medical officer and the regional executive director, who is a most impressive woman with an excellent and warm sense of humour.
Until eight years ago, there was no road to Masasi, which was essentially cut off from the rest of the country. Even today, the daily newspaper arrives at 6pm. The recent discovery of oil and gas in the region has brought great excitement and expectation but it will be a while, if ever, before these riches are translated into local prosperity. A sense of impatience is growing.
Maternity care is delivered by a range of attendants of varying skill and interest in obstetrics. Staff morale is low and there is a sense that people are beyond caring. They are used to patients dying, and will not always intervene.
In remote villages, access to care is a major problem. Getting to one of the three hospitals in the region in the midst of an emergency takes time; often, too much time. Local facilities are ill-equipped to deal with the obstetric emergencies that kill women. Ambulances are in short supply.
Women also are slow to access antenatal care and often do not attend until late in pregnancy, thereby missing vital opportunity to screen for malaria, HIV and risk. Malaria is a big problem here and pregnant women are offered free anti-malarial prophylaxis during pregnancy.
Unfortunately, fewer than 20 per cent of pregnant women attend for a first visit and only 40 per cent of women attend for any care before birth. It is well established that lack of antenatal care is associated with adverse outcome. Teenage pregnancy and poor nutrition create further challenges.
Lack of experienced obstetric care and dedicated obstetric training is stark. Women are frequently cared for by staff who have little training in childbirth and the emergencies that are such a frequent part of maternity care.
Lack of hygiene contributes to the sepsis rates, and simple things such as separating clean and dirty utilities and managing patient flow through theatre could do much to prevent perioperative infection. At ward level, mothers and babies need dedicated facilities.
Postnatal care is almost nonexistent but perhaps the most fundamental issue is lack of access to and uptake of family planning. The effect of unplanned pregnancy after pregnancy has a significant impact on poverty and mortality.
There are many reasons for this including the cultural more that good African women produce babies, lack of access, and lack of education, while both Catholic and Muslim ethos prohibit contraception. In addition, men have little interest in contraception and the uptake of vasectomy in the region is virtually nil. However, attitudes are changing as women become increasingly educated. Smaller families mean fewer mouths to feed and a better chance of providing education and securing a better future for their children. That is what Tanzania is all about just now. A better future. The sense of hope is tangible.
In the afternoon, I teach the students in a new nurses’ home that has been built with American aid. The students are a range of doctors, nurses and trainees. Most speak English and Swahili. I do my best with my four-day-old Swahili, but I am reasonably certain I was utterly unintelligible.
Slowly the conversation begins but soon grows more animated as we consider the theory of what to do in a range of emergency situations. I am miles from home in a familiar conversation.
This was one of the most exciting and fulfilling days I have ever had. We are using models to simulate clinical emergency scenarios so we spend the day resuscitating a range of babies, delivering second twins and rescuing babies stuck because of shoulder dystocia. We conquer breech deliveries with nuchal arms and we save our models time and time again from postpartum haemorrhage, maternal sepsis and maternal collapse. There is no model that cannot be saved.
At lunch, I earn universal disapproval for not eating vegetables which is part of my dedicated strategy to avoid the horrors of gastroenteritis. Everyone chats away and I have the chance to get to know more about my students. In exchange for lots of questions about Tanzania, I am asked about Ireland and I do my best to explain Gaelic football and brown bread.
I come back from lunch to find a group of students have come back early and are practising their newly acquired drills and skills. The afternoon is energetic and lively and we round off with a session on labour and management of the third stage of labour. It is clear that by training trainers, classes like this could easily become commonplace with little resource. That evening we travel the four hours back to Mtwara. I am tired, but I don’t want to sleep. I want to watch and see as much of the tiny villages as I can.
We are up at 6am to catch the flight back to Dar Es Salaam, where the rains have begun. Eventually we navigate the city gridlock and return to the office to hand over and discuss potential strategy to reduce maternal mortality in the region. There is lots to think about and discuss. Later, I return to pack for home. The million women who die in childbirth every three years feel very close.