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 20^th 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.

I sit on the steps to the hospital entrance sipping a warm Pepsi. People amble around me, chatting, laughing, and singing. Three old men are perched on a tree trunk, smartly dressed in suits, clutching bamboo canes and swinging their bare-feet in the dust. Two girls walk past with huge golden papayas balanced skilfully on their heads. A Masai tribesman draped in deep red robes paces under an acacia tree talking fervently into a mobile phone. Welcome to Berega.

I reflect on this week’s highlights. Unexpectedly I have found myself overseeing the paediatric ward. Two children were admitted over the weekend with soaring temperatures, bright yellow, and in deep deep comas. Every year, 18 million Tanzanians get malaria, and of these 60,000 die. Nearly all deaths are children aged under 5. The environment is just the right (or wrong) combination of warm climate and poor housing, leading to maximum biting from parasite filled mosquitoes. Children suffer the most as they have not had the years of exposure to the disease and ultimate resistance which that brings. The children we admitted had the most severe form possible, cerebral malaria, with involvement of the brain. Without treatment it almost always results in death. The team treated them diligently, we crossed our fingers, and watched anxiously on the first, second, and third days as they slowly improved but failed to revive from their comas. Then miraculously on the fourth day they were eating breakfast, and on the fifth day they both walked home.

Not all has gone well. I saw a two year old girl last week with Kwashiorkor, the most extreme form of malnutrition, whose parents refused to allow her to be treated in hospital. This is a life-threatening condition where the whole body starts to shut down, the most obvious manifestation being generalised body swelling, thin brittle hair, and a lethargic demeanour. This poor, tiny girl was so weak she was unable to cry, managing only a few muffled sobs. The mother, without an extended family to care for her remaining children, found it impossible to remain in hospital and fled overnight with her little girl. She has not returned and there is no way to trace her. The mortality of Kwashiorkor is high, and without specialist treatment and intensive feeding it is difficult to be optimistic. As a team we are deeply upset. We struggle to find some meaning or lesson to take from this. We muse on the huge social and economic pressure that illness puts on society, and especially on women. Mothers, daughters and aunts are relied upon not only to provide the most basic elements necessary for life (water, firewood, maize from the farms), but also to remain in hospital providing the majority of nursing care for sick relatives. This mother was forced to choose between the health of her daughter, and the feeding, warmth and security of her entire family. Perhaps without her presence at home another child, deprived a few bowls of maize porridge, would drop a few calories closer to malnutrition. Akin to Sophie’s choice, no one can hold her responsible for her disappearance from hospital. Unfortunately, the problem is not as simple as sending money, or food. Something, somewhere in the great antiquated systems driving economic and gender inequality is to blame. We must strive to fix this. We must think. We must learn. And in the meantime, we must do our best with the remaining patients.

I spend the evenings attempting to learn Swahili. On the whole my speaking is unintelligible, with occasional flashes of fluent idiocy. Thankfully, instead of demanding my immediate resignation, the patients have the grace to laugh. A ward round begins as I ask a giggling mother whether her baby has been doing much cooking the past few days. At the next bed the impeccably polite nursing staff cannot hide their grins as I enquire how beautiful a boy’s stools have been. Finally, as I leave the bedside of particularly terrified looking six year old girl I’m informed that I’ve just told her that a goat will be along to weigh her.

So as the sun sets over the dusty, green valley, my solar powered computer battery slowly dies. I hope to write again soon. Even during the past few days I’ve accrued a year’s worth of stories- hope, sadness and futility thrive here. Thank you for reading.