Tanzania's shame:

The young woman had already been in labour for two days by the time she reached the hospital. Now two lives were at risk, and there was no choice but to operate and take the baby right away.

It was just before dawn, and the operating room, powered by a rumbling generator, was the only spot of light in this village of mud huts and maize fields. A mask with a frayed cord was fastened over the woman’s face. Moments later the cloying smell of ether filled the room, and then Emmanuel Makanza picked up his instruments and made the first cut for a Caesarean section.

Makanza is not a doctor, a fact that illustrates both the desperation and the creativity of Tanzanians fighting to reduce the number of deaths and injuries among pregnant women and infants. Pregnancy and childbirth kill more than 5,36,000 women a year, more than half of them in Africa, according to the World Health Organisation.

Most of the deaths are preventable, with basic obstetrical care. Tanzania, with roughly 13,000 deaths annually, has neither the best nor the worst record in Africa. Although it is politically stable, it is also one of the world’s poorest countries, suffering from almost every problem that contributes to high maternal death rates — shortages of doctors, nurses, drugs, equipment, roads and transportation.

There is no single solution for a problem with so many facets, and hospital officials in Berega are trying many things at once. The 120-bed hospital here — a typical rural hospital in a largely rural nation — is a case study in the efforts being made around Africa to reduce deaths in childbirth.

One stopgap measure has been to train assistant medical officers like Makanza, whose basic schooling is similar to that of physicians’ assistants in the US, to perform Caesareans and certain other operations. Tanzania is also struggling to train more assistants and midwives, build more clinics and nursing schools, provide housing to attract doctors and nurses to rural areas and provide places for pregnant women to stay near hospitals so that they can make it to the labour ward on time.

But there is a shortage of Makanzas, too. As he began to operate, he said he should have had another pair of skilled hands to assist him. But, he said, “we are few.”

Nightmare

There are many nights like this at the hospital here, six miles from the nearest paved road and 25 miles from the last electric pole. It is not uncommon for a woman in labour to arrive after a daylong, bone-rattling ride on the back of a bicycle or motorcycle, sometimes with the arm or leg of her unborn child already emerging from her body. Some arrive too late.

A few minutes’ walk from the hospital is an orphanage that sums up the realities here: it is home to 20 children, all under three, nearly all of whose mothers died giving birth to them.

At times, Makanza performed one Caesarean after another, sometimes in the middle of the night. One mother was only 15. Another had already had two Caesareans, adding to the risk of this operation or any future pregnancies, but she declined Makanza’s recommendation to be sterilised.

Others had hoped to speed their labour by taking herbal medicine but were suffering dangerously strong contractions. Hospital staff members struggled to keep up with the operations, handwashing bloodstained gauze and surgical drapes in basins and mopping blood from the floor between cases.

Women in Africa have some of the world’s highest death rates in pregnancy and during childbirth. For each woman who dies, 20 others suffer from serious complications, according to the WHO. In 2000, the UN set a goal to reduce the deaths by 75 per cent by 2015. It is a goal that few poor countries are expected to reach.

Tanzania has reduced its death rate for young children, but not maternal mortality. The ministry of health says its maternal death rate is 578 per 1,00,000 births, but the WHO puts the figure at 950 per 1,00,000. By contrast, the health Organisation estimates the rate in Ireland, the world’s lowest, to be one per 1,00,000.

Experts say that what kills many women are “the three delays” — the woman’s delay in deciding to go to the hospital, the time she loses travelling there and the hospital’s delay in starting treatment once she arrives. Only about 15 per cent of births have dangerous complications, but they are almost impossible to predict.

Women lack education and information about birth control, and some become pregnant too young to give birth safely. Husbands and in-laws may decide where a woman gives birth and insist that she stay at home to save money. Malnutrition, stunted growth, malaria and other infections, anemia and closely spaced pregnancies all add to the risks.
Unaffordable service
In rural areas, many women use traditional birth attendants instead of going to the hospital. The attendants usually have no formal training in medicine or midwifery. Around Berega, they charge about $2 per birth. A normal birth at the hospital costs about $6, an emergency Caesarean $15.
Even though it serves an area with about 2,00,000 people, the hospital in Berega has no obstetrician or pediatrician. It has only one fully trained doctor, Dr Paschal Mdoe, 31, who became the medical director in August, fresh out of medical school.
Like most hospitals in Tanzania, the one in Berega tries to compensate for the doctor shortage by relying on assistant medical officers like Makanza to perform many Caesareans and a few other relatively simple operations like hernia repairs. Although such assistants eventually become quite adept in such operations, most other countries do not recognise their credentials and so do not try to lure them away, a big plus for Tanzania, which loses doctors and nurses to Botswana and other countries that pay more.

Periodically, visiting surgeons repair fistulas, a severe childbirth injury that causes incontinence in the mother. Some experts have also taught staff members how to resuscitate newborns and treat obstetrical emergencies like hemorrhages and severe high blood pressure.

To persuade more women to give birth at the hospital instead of at home, the hospital is sending health workers with that message to marketplaces, churches, village elders and religious leaders.
In addition, the hospital is creating a ‘maternity waiting home’ so that pregnant women who live far from the hospital can travel to Berega before labour starts and have a place to stay until it is time to give birth. Officials are also negotiating with the government to cover all fees for pregnant women and children, and to acquire an ambulance.

To attract staff members, the hospital provides concrete houses with access to a pump. The church ‘tops up’ government salaries for doctors and nurses, and Dr Mdoe successfully lobbied church officials to give his staff a raise. A nursing school is being built, with the hope that it will draw local students who will want to remain in Berega.