Visiting district staff in Bagamoyo this week to work with the health district to move forward on putting together a maternal and neonatal health program. Every time I go there I learn so much more, particularly about the awful state of the health system. It can be overwhelming. This time it is about trying to figure out how education, advocacy, and potentially using cellular technology could help to improve the quality of care.
Bagamoyo Health District covers a huge area. There is one hospital somewhat unfortunately located in a far corner of the district and often isolated from the rest of the district due to the poor quality of the roads. Beyond that there are four health centers, which are the next lower level of facility, and 50 dispensaries, which offer fairly basic care. The district, like Tanzania as a whole, is desperately short of health workers, and the health workers it has are heavily skewed toward medical attendants, who make up 60% of the work force and have no training. They are referred to as 'cleaners and sweepers,' even though out of necessity they wind up doing much more than that.
In addition, about two-thirds of the dispensaries have no running water or electricity. Those that do have running water and electricity in theory often do not. This week, even the hospital spent a day with no water supply, and electricity is an enormous issue in the country. There is not enough power generation to come close to meeting demand, so blackouts are a daily occurrence. Even the hospital has no back-up generator so when the power goes out, as it does every day, you can't operate any equipment. It is, to say the least, a series of enormous challenges.
The reason we are putting together the maternal and neonatal health program is because Tanzania has some of the highest rates of maternal and neonatal mortality in the world. The country currently has little hope of meeting improvement targets, called millennium development goals, that every developing country on the planet is currently trying to achieve by 2015.
Imagine that you are a pregnant woman in a village in the Bagamoyo district, living 100km from the hospital. The hospital may not really even be accessible during the rainy season when the roads turn to mud. The main highway is a good road, but is a fair distance from your village and is of little use for getting to Bagamoyo hospital. You would have to go all the way down south to Dar es Salaam, and back up north on the coast road which then stops at Bagamoyo. Not helpful.
Your closest health facility is a dispensary several kilometers away that has no running water or electricity. To give birth at this facility requires that you bring a) a bucket of water, b) a khanga (cloth wrap women wear) to serve as your sheet, c) surgical gloves, and d) a razor blade to cut the umbilical cord. In addition, once you get to the dispensary it is just as likely that the person there to help you is an untrained medical attendant, and equally likely there will be no electricity. If you cannot afford surgical gloves (which is common) they may have some at the facility that someone will sell to you (you may have to take up a collection in the village to pay for this before release). A clean birthing environment is unlikely (remember there is no water even for hand washing), and if you have any complication there will be nobody at the facility, nor much in the way of necessary equipment, to help you. You can try to get to a higher level facility, but if one of the three ambulances in the district is unavailable (which is likely), you would need funds to hire a taxi or bajaj (a.k.a., tuk-tuk) to get you there. Most people cannot afford this.
Given the relative unattractiveness of going to a dispensary, you are more likely to choose to give birth at home. You have two basic options, including a) having female relatives or women in the village assist you, or b) having a traditional birthing attendant (TBA) help you. Most people in Bagamoyo District start with a traditional healer for any health issue, which may work fine. However, if it does not, by the time they get to a health facility something that may have been relatively simply treatable is now life-threatening. TBAs have little to no capacity for dealing with birthing complications, offer no antenatal care, and there is an increased risk of transmission of infection, notably HIV. They will, however, often stay with the mother to help in the first few days post-delivery. That may not be possible for women in the village, who need to work.
There really are not particularly great options for giving birth. That said, there are many healthy babies born without complications. Unfortunately, it doesn't take a lot for the situation to turn life-threatening for the mother and/or infant.
There are a lot of barriers to having a significant impact on maternal and neonatal mortality, particularly those that are sustainable. One could throw resources at a facility, for example, but once the project is gone, what happens then? For example, there have been projects that have provided hand sanitizer, which lasts a very short time and is gone. What we are looking at is creating relatively simple interventions, mostly educational, also some basic tools, that can have impact and be sustainable, while simultaneously building the case for infrastructure improvements that would help facilitate sustainability. Clearly, any plan needs to include the communities and the TBAs. There simply are not enough resources, human or financial, to deal with every aspect of the problem that needs addressing. You have to move forward a step at a time.
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