May 24, 2009
Death in Birth
Where Life’s Start Is a Deadly Risk
By DENISE GRADY
BEREGA, Tanzania — The young woman had already been in labor for two days by the time she reached the hospital here. 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.
Mr. 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 536,000 women a year, more than half of them in Africa, according to the World Health Organization.
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 Mr. Makanza, whose basic schooling is similar to that of physicians’ assistants in the United States, 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 labor ward on time.
But there is a shortage of Emmanuel 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.”
He made a quick, vertical cut, working down from just below the navel, through one layer at a time: skin, fat, muscle, the peritoneal membrane. Within three or four minutes he had reached the uterus, sliced it open and wrestled out a limp, silent baby boy exhausted by the prolonged labor and knocked out by ether. It took a nurse 5 to 10 minutes of vigorous resuscitation to get him breathing normally and crying.
There are many nights like this at the hospital here, 6 miles from the nearest paved road and 25 miles from the last electric pole. It is not uncommon for a woman in labor 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. In October, a mother who had been in labor for two days died of infection. In November and December, two bled to death. Doctors say they think that more deaths probably occur outside the hospital among the many women who try to give birth at home.
A few minutes’ walk from the hospital is an orphanage that sums up the realities here: it is home to 20 children, all under 3, nearly all of whose mothers died giving birth to them.
“You can never get used to maternal deaths,” said Dr. Siriel Nanzia Massawe, an obstetrician and the director of postgraduate studies at Muhimbili University of Health and Allied Sciences in Dar es Salaam, the country’s largest city. “One minute she’s talking with her husband, then she is bleeding and then she is gone. She’s gone, very young. You cannot sleep for one week. That face will always come back to you. Too many die, too young. But the people in power, they have not seen it. We need to make them aware.”
Over the course of several days at Berega, the difficulties became clear. At times, Mr. 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 Mr. Makanza’s recommendation to be sterilized.
Others had hoped to speed their labor 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.
Two women had severe problems from high blood pressure. One came to the hospital after giving birth at home and having a seizure. Another delivered a full-term infant who had died in her womb at least a week before; her only other pregnancy had ended the same way.
A mother in the maternity ward had arrived in labor with twins, one already dead. A Caesarean had saved the second.
The Global Perspective
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 W.H.O. “Maternal deaths have remained stubbornly intractable” for two decades, Unicef reported last year. In 2000, the United Nations set a goal to reduce the deaths by 75 percent by 2015. It is a goal that few poor countries are expected to reach.
“Why don’t we have a global fund for maternal health, like the one for TB, malaria and AIDS?” Dr. Massawe asked.
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 100,000 births, but the World Health Organization puts the figure at 950 per 100,000. By contrast, the health organization estimates the rate in Ireland, the world’s lowest, to be 1 per 100,000.
The women who die are usually young and healthy, and their deaths needless. The five leading causes are bleeding, infection, high blood pressure, prolonged labor and botched abortions. Maternal deaths from such causes were largely eliminated nearly a century ago in developed countries. In poor countries a mother’s death leaves her newborn at great risk of dying as well.
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 traveling there and the hospital’s delay in starting treatment once she arrives. Only about 15 percent of births have dangerous complications, but they are almost impossible to predict.
A Medical Emergency
A case in the Tanzanian city of Moshi late last year reveals how suddenly a seemingly normal labor can turn into an emergency in which every second counts. Hawa Khalidi, 36, who had five normal births, gave birth to her sixth child a few hours before dawn on Nov. 19 at a health center staffed only by nurses in one of the poorer sections of the city.
Then she began to hemorrhage, and by daybreak she was dead.
An autopsy found that Mrs. Khalidi bled to death because the nurse who delivered her baby failed to perform one basic task, essential to prevent deadly bleeding: removing the placenta after she gave birth.
Normally, pulling on the umbilical cord will extract the placenta. But the autopsy revealed that the cord broke off. The nurse apparently did not know how to reach into the womb to remove the placenta. She sent Mrs. Khalidi to a hospital, but by then Mrs. Khalidi had lost so much blood that doctors could not save her.
In an interview, Mrs. Khalidi’s husband said nurses at the clinic had scolded her because she was too poor to bring her own “delivery kit” containing gloves, clamps and other supplies. Some maternity wards are so crowded that women sleep two or three to a bed, or lie on the floor, along with their newborns. Although the government has promised to build more clinics and to put one within three miles of every village, it cannot even fully staff the clinics it already has. Health workers — overworked, underpaid and sometimes poorly trained — often become demoralized and resigned to the high death rates.
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.
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. Many doctors blame them for high rates of maternal death and complications, saying they let labor go on for too long, cannot treat complications and fail to recognize emergencies that demand hospital care. But many women are loyal to them. For one thing, the price is right. Around Berega, they charge about $2 per birth. A normal birth at the hospital costs about $6, an emergency Caesarean $15.
Dr. Jeffrey Wilkinson, an obstetrician from Duke University who is working at the Kilimanjaro Christian Medical Center in Moshi, pointed out that other African countries, like Niger, had even higher maternal death rates. Despite the many obstacles in Tanzania, “there is hope here,” he said.
A Hospital’s Shortages
Even though it serves an area with about 200,000 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 Mr. 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 recognize 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. Other outside experts like Dr. Wilkinson 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 labor 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. (The hospital, a mission institution supported partly by the Anglican Church and the government, does not receive enough money to cover its costs, so it charges fees to make up the difference.)
But there is a long way to go. Only 20 percent of women in the area give birth at the hospital, and many do so only when they need Caesareans. Many women say they simply cannot afford the hospital. More than 50 percent stay home to give birth, and the rest go to local clinics that cannot handle emergencies or perform Caesareans.
“We lost four or five babies this week,” the Rev. Isaac Y. Mgego, an Anglican priest and the hospital’s director, said in an interview in January. “Our doctors have to play with two bad things, to save the mother or save the child.”
It is not easy to lure doctors and nurses to Berega, where most people live in mud huts with no electricity, flush toilets or running water. Malaria is common.
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.
The hospital has four nursing officers, 10 midwives and 2 other workers known as clinical officers, a total of 16.
“We used to have 34,” Mr. Mgego said. “People leave. We are struggling to retain them. They don’t want to live in villages. Some go without saying goodbye. Those who are committed, they are working tirelessly.”
It costs about $200,000 a year to run Berega Hospital, Mr. Mgego said. He said he hoped the hospital would find ways to prevent the serious problems that required mercy missions and visiting surgeons from groups like Amref, the African Medical Relief Foundation, also known as the flying doctors.
“Coming here to cure people is good, but what can we do to prevent this?” Mr. Mgego asked. “So that one day we can say, flying doctors, you can come, but we have only one patient, or nobody, around here.”
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