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Sunday 8 September 2013

Maternal mortality in rural Tanzania

OK. So in these situations it's best to start with the bad news first. Today we had what is probably the first maternal death since I have arrived here. The story is a tragedy, one of a system so inadequate, of a world set up with such injustice. If it seems I'm being dramatic I will start at the end, where I face a problem which my 3 months working in rural Africa has not prepared me for. A nurse and I are discussing with the family how they will take the body home. The body is that of a 25 year old woman. The mother, aunt, and sister of the woman feel they have no alternative but to take it on the back of a motorbike.

This young woman started feeling unwell several days ago so she visited a local chemist and was treated for malaria. Despite treatment she developed abdominal pain which gradually worsened. By this morning the pain was excruciating, and the family meet to discuss what to do. They quickly realise she must go to hospital, but due to the fact they are subsistence farmers, have no money to pay. Twelve hours go by whilst they borrow and negotiate with neighbours and distant relatives to find money and transport to get from their isolated village to us. Finally, now semi-conscious, she is sandwiched on the back of a Chinese motorbike to drive the thirty-odd kilometres along bumpy dirt roads.

As her limp body jolts against the force of every stone in the dusty road she gets sicker and sicker. Her fallopian tube is leaking blood, split open days ago by a gradually enlarging ectopically implanted fetus. By the time I see her, a critical amount of blood has seeped out of her blood vessels into her rapidly expanding abdomen. Her heart is racing, she has no blood pressure. I pull down her eyelid- it is as white as paper. I touch her hand- cold as stone. She has no blood left.

I plunge two huge needles into her arms and squeeze in two litres of fluid in an attempt to keep her blood pressure up. I know that two things can save her- rapid blood transfusion, and an immediate operation to remove the bleeding fallopian tube.

We have a beautiful blood fridge, donated by the US government. It sits, unplugged and empty, in the corner of the lab. We have no electricity to power it. A New York Times article came out about maternity surgery in our hospital several years ago, discussing the challenges of working without power. Some truly great soul read this and provided funding to bring the national grid to Berega. A few weeks ago a pole was erected outside the entrance to the hospital. This single act will one day save countless lives. But for now, we still have no electricity. At the same time several shops and houses around the hospital have all the electricity they desire. Every day I ask why and receive a different answer each time- someone says they are waiting for a special wire to connect it which must be imported from South Africa, someone else says that a politician is waiting to be paid off. The truth is that you can buy a refrigerated coke from the shack opposite the hospital, but still we can't run a refrigerator to store blood.

So, minutes after I start squeezing fluid into this woman's vessels and long before we go through the process of finding compatible donors to rapidly replace her leaking blood and long before we assemble the anaesthetist, theatre nurse, call the guard to switch on the emergency generator and wheel the woman to theatre to triumphantly stem the bleeding, she stops breathing, under torchlight in the corner of the female ward, surrounded by a team of medical professionals powerless to do anything but look. We start to resuscitate and after discussion we take the hard decision that without blood on standby our efforts are futile. We look, at each other, at the woman, at our feet, someone holds their head, another wrings their hands, and others' hands rest on colleagues' shoulders. My adrenaline is still high, but suddenly there are no tasks to be completed, or orders to bark. I take a nurse and explain our failure to the family. The kind nurse translates, explains and comforts. I've never heard a sound as disturbing as a mother's anguished wail. I'm not sure what to do in the face of such grief so I look at my feet again. It feels like a horrible film, but the scene won't cut, and we have to go on living it.

And now we come full circle, back to the beginning of my story, and the end of this one, the end for this woman, with her aunt, pulling me aside, asking me to hurry the writing of the death certificate because it is late in the night, they have very little money, and they must get the body home. The motorbike which brought them here is waiting outside, and they don’t want to miss it. I urge them to leave the body here in the mortuary, to be picked up in the morning. I almost give them the money to hire a car, but stop myself- my funds are already limited, and there will be other people, living people, on whom I can spend money to transport to the local referral hospital.

The cycle will repeat itself, day in, day out, in Tanzania’s rural areas, in which 80% of people live. The tribe I live amongst- the Kaguru people- are a wonderfully warm community, whose culture centres on the utmost care of the extended family, and the proud welcome of strangers, like me. Hospitality is in their DNA. They are rewarded with a callous and corrupt government, poor roads, appalling public transport, ill-equipped hospitals, and a creaking education system. People want change. Not necessarily the Coca-Cola, satellite television type of change which is the inevitable first wave of development, but some sort of infrastructure which helps you make it past your fifth birthday, and stops pregnancy being a dice with death. For every 100,000 pregnancies here, 460 end in the death of the mother, giving Tanzania the dubious honour of having the 20th highest maternal mortality ratio in the world.

Ruptured ectopic pregnancy accounts for 1 in 20 maternal deaths in Africa. Perhaps because they are not as easily boxed or understood as infectious diseases like HIV and malaria they receive relatively little attention. The facts are that in countries like Chad and Afghanistan the current maternal mortality rates are about the same as medieval Europe. The majority of causes are from bleeding around the time of delivery, infections after delivery, disorders of blood pressure related to pregnancy, and obstructed labour, often requiring a caesarean section. The consensus of the WHO is that these can all be prevented, or picked up early enough to be treated, by having a trained health practitioner (midwife, nurse, or doctor) present at the time of delivery. This of course requires well-trained healthcare staff, the money to pay them, and the infrastructure to allow them to work. The solution is comprehensible, but the challenges in delivering it are vast.

I said that I would start with the bad news first. The good news is that this week I treated two women with septic miscarriages, who both arrived very sick, and getting worse, who turned the corner, recovered and have gone home. They are two people who will not be added to the maternal mortality statistic. As a doctor, when you see the scale of the problem, it is easy to think that what you are doing is so insignificant as to not be worth it. But I'm learning that the solution to the big problem of maternal mortality is not about big ideas. It starts with lots of people doing small things, helping the patient in front of them, and improving small parts of the system which they have the power to do. This is what we are trying to do here at our little hospital, nestled into the mountainside in Berega, working hard to break the cycle.