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2009-02-12

Maternal Health Care in Kagera Region, Tanzania

Why mothers come late for emergency obstetric care

I went to Tanzania in 2007 to do my Ph.d. study and find out why pregnant women come too late for treatment when they suffer complications. In Tanzania the risk of women dying in relation to pregnancy and childbirth is hundred times higher as in Denmark. UN fifth millennium development goal is to reduce maternal mortality 75% by 2015. The strategy for achieving this goal is to get 90% of all births to take place with a "skilled delivery attendant" - a midwife or a doctor. Half of the women in Tanzania give birth at home and the aim of my study was in the beginning to clarify why many women do not seek the services of the health system. I observed births at home, at small health posts and the large regional hospital and spoke with the families and the involved birth attendants. Doctors and midwives said that many women are "indifferent" to their health, are "ignorant" and "lazy" or that there are "cultural barriers". This image was difficult to recover when I spoke to the women and their families, they explained that it was first and foremost economic conditions that could prevent them from reaching the health post or hospital. I examined the preparedness to deal with birth complications at the health posts in the villages - it proved to be very sparingly. During the month I spent at the regional Hospital several maternal deaths took place, all of which could easily have been avoided.

Maternal deaths at Kagera Regional Hospital

I will never forget the Saturday morning I arrived at a chaotic labour ward where two midwives struggled desperately. A woman who was delivered two hours previously, lay unconscious bleeding heavily. The floor sailed in her blood. I quickly got a white coat and gloves on and had compressed the uterus so that the bleeding stopped. I got intravenous access, got a saline drip running and administered medications to contract the uterus. I could not feel the woman's pulse and the blood pressure was immeasurable. Her mucous membranes were snow-white as a sign that she had lost most of her blood. The staff of the blood bank had not met at work yet, so we got no blood. The woman had cardiac arrest and we began resuscitation. The oxygen concentrator did not work, because there was a power cut and the emergency generator was not deployed. The mask and the balloon to blow air into her lungs were old and leaking and practically useless - there was nothing we could do. We had to give up and go the heavy way out to her husband and tell that his wife had not survived the birth - he practically melted in the hands of me - fell lax on the stairs and wept as he shook. Two daughters were in their finest dresses to say congratulations to their mother - I will never forget their sweet, expectant smile, with a stroke turned to deep despair and horror - they wept and screamed and ran around wild, while they tore the clothes off the washing from dry rope outside the maternity ward. At this moment the doctor in call arrived, three hours after he had been summoned. "This is life at a hospital," he said with a smile, "Shit happens". I was not able to answer him. While I was at the hospital a second woman died in the same way from exsanguinations, a third of eclampsia (hypertensive disorder of pregnancy) after being treated wrong and too late, a fourth had a retained placenta, which was not removed in seventeen hours, so she died of severe infection, a fifth had an infected illegal abortion that did not get the evacuation of the uterus that could have saved her life.

Facility delays in emergency obstetric care

It appeared to me that I might have looked in the wrong place searching for why women with birth complications were treated too late. It was perhaps not the women who were "indifferent" and "came too late" - but the health system that failed. I went through the health statistics. In Kagera region virtually every registered maternal death occurred in a hospital. I found the case files went through the record books and operation records and interviewed staff, and the picture was becoming clear. Five out of six maternal deaths at the regional hospital occurred because of missing or significantly delayed treatment. Half of the women who died had been hospitalized two days or more before they died.

Advanced Life support in Obstetrics (ALSO)

I decided to change my study focus and try to see what impact it would have to train staffs in Emergency Obstetrics Care - the basic skills to handle pregnancy and childbirth complications. I chose to work with Advanced Life Support in Obstetrics (ALSO), which is the most common obstetric emergency training course in the world - I was in the U.S. and got the green light to start the course in Tanzania, went to England and was trained as ALSO instructor and managed to get together a good team of trainers. I revised the course content so that it matched African conditions. In September 2008 we carried out the first ALSO courses in Tanzania for the staff at Kagera Regional Hospital. I had been very curious about how everything would go, but the reception was overwhelmingly positive. With a team of research assistants I had followed the deliveries at the maternity ward in the months leading up to training. All women had the bleeding after birth measured - it turned out that every third woman was bleeding too much, more than half a litre. At the ALSO course, we used role-playing and training mannequins to practice the simple skills that can stop any bleeding before it becomes life threatening. In the months after the training the number of women bleeding more than half a litre was reduced by 50%. Bleeding after childbirth is the most frequent cause of maternal deaths and with the ALSO training we showed that short, intensive training can improve the health of personnel handling considerably. The course lasting two days also addressed a number of other important maternal and neonatal complications and had a positive impact on other topics than bleeding complications. For example was neonatal mortality reduced. The courses were a great success and since then four more courses were conducted and a number of Tanzanian instructors trained. More courses are planned and we have now established a network among ALSO groups in Kenya, Rwanda, Malawi and Tanzania with the aim to document, develop and disseminate the course. In 2009 and 2010 there are plans to start ALSO in Ethiopia, Uganda, Zambia and Liberia.

Bjarke Lund Sørensen