An Englishman, Childbirth and Rural Tanzania: 06. She aint heavy

06. She aint heavy
28th July 2013

From anywhere to anywhere in Tanzania is a long, long road. (If there is one.) The 2012 census on everything-you-need-to-know-about-Tanzania has just been published, and please remind me to annexe some of the stats, for any geography teachers who have strayed onto the wrong blog from Ibetyou’reregrettingchoosingthisforOlevel@boringfacts.blogspot.com.

Just to whet your appetite, here are some of the dusty details:

The country is humungous. It measures around 900km x1000km. They haven’t yet got around even to begin sorting out great chunks of it. In these areas, hordes of wildebeest trundle, and groups of Masai squat by evening fires, as they have done since wildebeest first said “What are those spiky things squatting by that evening fire, and why are they eating mum?” These areas form the 30-odd National Parks and Game Reserves. The Selous alone – one of the largest Game Reserves in the world – is about the size of Southern-England-without-the-sticky-out-bits. In the Game Reserves, there are no good roads, no service stations, and no-one thumbing a lift for very long.

Perhaps the penning of predators into these vast savannahs is one the reasons that the population is now expanding at about a million extra people per year. (There is still plenty of space, though. Tanzania has lots and lots of wild and wonderful space, and surely, one day, a healthy future because of it.) Despite the expansion, the current population of the mainland is still only 45m – less than three-quarters that of the UK. The avoidance of being eaten might be helping the growth, but more importantly, having enough children is a protective response to some grimly depressing factors reflected in the census.

In the rural populations, a household will typically comprise four or five people, and many graves. One in 25 homes has electricity; one in 3 has safe water nearby; one in twelve has any sort of poo-hole; and more than one in three families subsist below the poverty line.

No living children means no living, once past a certain age.

It is not too surprising then, that the 2012 census continues to show that rural Tanzania carries on having one of the worst maternal mortality figures in the world. The best is Estonia, for some extraordinary reason. (Plenty of fish, and an overwhelming desire to produce a Eurovision Song Contest winner?) In Estonia, 2 women die in every 100,000 live births – an awesome twenty-fold reduction in three decades. In Tanzania, the 2012 figure was 454, making the lifetime chance of dying in childbirth nearly 1 in 20 women.

It has always been like this, of course, and people know no different. Indeed, a comparison of the census stats with those from primitive territories with no access to health care, reveals that it would not be much worse if no hospitals existed in much of the isolated areas. The reason is simple: no hospitals exist in much of the isolated areas.

On Monday, we went to visit one that actually is there – Mvumi. It was our first trip further inland, and we had to pass through the capital of Tanzania, Dodoma. From our hospital, it is about twenty minutes to the main road, and then a bit more than a two-hour drive to Dodoma. (More still if you get stuck behind a convoy of trucks headed for the deep interior. Even more if you get squashed by one. In Tanzania, a dual carriageway is where a bike with innumerable twentyfive-litre water containers tied into a Santa’s sack-load can overtake another bike with a small copse of charcoal-grilled saplings balanced across the back wheel, without having a head-on collision with a motorbike taking an extended family to market with their spare goat.)

On the way, we pass through Gairo. Gairo is the only town other than our own, in the 263km between Morogoro and Dodoma, to have a hospital. They are bidding to become the District Hospital in 2015, for which they will have to fix the fact that they have no doctors, no AMOs, no transport, and no caesarean facility. Gairo looks just like a town from the Wild West – ox carts, a single wide main dirt road with a single turning, and frontages of entrepreneurial shops – spare-tyre salesmen, barbershops, ironmongers, mop-and-bucket outlets, and makeshift eateries. It just needed thistledown and Gary Cooper. We stopped at the Rusty Axle Corral to get our tyres checked, and I kept look-out for Lee Van Cleef.

From Gairo on to Dodoma the thing that struck me most was the lack of turnings. I don’t just mean motorway junctions, I mean turnings. Any turnings. Every twenty kilometres or so, a grubby finger would point down a packed-earth track, and say something like ‘Chagongwe 71km’. You get the feeling that they would be 71 challenging kilometres, and you hope that Chagongwe would be worth it. If you were to look back at your various map and GPS sources, you would find that there is actually just one road: East to West, Morogoro to Dodoma, and then on to Rwanda. For a county or two north and south, there is nothing except barely recognisable dry-mud tracks. Just one tar road - point the car in the right direction, and you will end up in Dodoma: A wife’s navigational dream. (Actually, perhaps not. Let’s say, a wife’s navigational dream once the car is pointed in the right direction: “Darling, we seem to be in Sweden instead of Barcelona. Are you sure we turned right at France?” “It’s not my fault. The map’s on my knee, and I feel sick when I look down.”)

Dodoma will one day be a much-sought-after place to live. At 3,700 feet, it has the perfect climate. It is the seat of parliament, has two major universities, is at the centre of the country, is throbbing with life, has an enormous central fruit and spice market, and has places to sit and drink tea in the gentle dry warmth of the morning sun. But it is still very young, and is about as cosmopolitan as the Outer Hebrides in winter. In an hour of taking it in, we saw one Arab, one Asian, and two people in the distance who by their shorts, sunglasses, safari hats and glisten of factor-50 anti-flying-things-besmeared skin, might have been European. We stopped for a bite to eat, were given a menu, but were told that nothing on it was available, so we wandered until we found another café. We made our own coffee from flasks of hot water, then tucked into chapatti and banana, not risking the chicken soup. I had been lulled into thinking that the gas cooker was the source of the chapatti, but as you picked your way through the back yard to the loo, there was an open fire on the ground, and something was baking in an ancient pan. Hopefully not a previous customer.

Mvumi hospital is about an hour’s drive from Dodoma. Even though I am more used to Tanzania now, I could not readily assimilate the idea that the main road out of the capital city, to the nearest main hospital, is only tarmacked for the first mile. Thereafter yellow clay became red packed dirt. You could sense that a hot sun beats down on this high plateau for much of the year. Mountains formed a distant surround, and the countryside was of scattered cacti, scrubby bush, brave but stunted acacia, and bizarrely-shaped humps of rock, presumably flung out during a primeval subterranean altercation. Mvumi hospital itself was the size of a large village, or even a small town. We were met by some of the happy and inspiring team that lead not just the hospital, but the training of Clinical Officers. COs are the level below AMO, (themselves the level below medical doctor). COs are the medical front-line in Tanzania. A three-year course, and a school-leaver is ready to triage the sick, and dictate the initial management of everything from aardvark bite to zoonosis. Quite incredibly, this unassuming institution, seeing the vast need in this vast terrain, in a few years has gone from self-funding mission hospital to (mission-led) Government funded District hospital, where no fewer than 150 Clinical Officers are in training. They helped us hugely in our quest to plan the future training of COs at Berega, and we left with half a terabyte of curricula and protocols, as well as much inspiration, and plentiful tea.

On the way back, the full moon rose at sunset, and tried to pretend that it hadn’t been shirking for much of the previous month. Driving the long road back by the light of the moon, (and the headlights, thankfully), was an almost eerie experience. Out there was Africa in the raw. From time to time, Masai on the side of the road would whip in their cattle, still uncomfortable with the intrusion of the last century or two.

On Friday night I treated my first Masai. Few come to hospital for childbirth, but this young girl was brought by her mother because of headache and profound swelling of the face and legs. Of course she had severe pre-eclampsia. She had no idea how far pregnant she was, but I guessed around 28 weeks. She seemed adolescent, but Masai do not seem to count age in years. We initiated therapy, but the only way to stop the process before it kills the mother is to deliver, and our neonatal unit consists of a slightly warmer room with no cots, and four mums’ beds packed rather too close to each other.

The girl’s mother was striking: tall, lean, and deep black in colour, but with almost European features. Smooth, unwrinkled skin, despite a few grey hairs. Thick-soled bare feet with toes splayed like fingers, as they are in humans who don’t wear shoes. A thin layer of dirt on much of the strong but feminine arms, but no unwashed odour, except perhaps one of good earth. Her ears were pierced to receive ornaments the size of cotton-reels, and round her neck were layers of white-toothed strings. Protecting the wrists and ankles were many-ringed spirals of gold-coloured bracelet. Three lengths of characteristic Masai coloured cloth were knotted in various ways around her body to form her garment.

There followed the uncanny experience of four languages. I tried to explain in English to the nurse, that we needed to transfer the girl. The nurse was Kaguru-speaking, but reverting to the common parlance of Swahili, was able to get the message across to the mother, who transmitted snippets to her daughter in the Masai tongue. The message I got back was that the father had gone to sell a cow to pay for treatment, and would not be here until the morning, so transfer was out of the question. We repeated the magnesium and blood pressure treatment, and did not need to tell the girl’s mother to sleep under the bed and watch her over night, as that is where all the women’s mothers sleep in our ward. Of course she did later have a fit, which was almost a relief, as I dreaded the idea of sending such a time-bomb so far, for potentially so unlikely a benefit. We did the caesarean this morning. The girl’s mother sat on the grass outside the theatre block, waiting to receive the child, whom we knew was not for this world. In traditional Masai culture, a birth is not even recognised for the first three months of life, because death is so common.

This caesarean experience was in stark contrast to the rest of the week and indeed the month. Although sometimes slipping in the aim to get things moving promptly in obstetric emergencies, we have generally got it right. Last night I did my second successful Kiwi for mal-position, delightfully easy, and saved a weepingly grateful mother of three the expense and morbidity of a caesarean. Until yesterday we had not had a single death all month from obstructed labour. (Our normal tally of deaths at birth has been about 1 in every 11 births, amounting to sometimes more than a dozen deaths a month.) But yesterday we did slip. In the busy yet casual, ill-structured day of the maternity block, somehow a mother managed to be in labour for ten hours before anyone noticed. We have yet to find out whether it was because the staff do not have the routines to ensure that such events do not occur, or whether the mother was coaxed to the hospital perimeter, as happens, to be given illicit doses of labour-enhancing tea. Between dawn and 3pm, the baby had died of obstructed labour.

By a strange irony, it was yesterday morning that the Hospital Director had called the follow-up meeting to last week’s exploration of how we might, systematically, do better. In attendance were the next layer down of three bosses of staff, plus myself, Sion, Dan, and the Director and Deputy. I needn’t have worried about how I was going to gently tease the idea of standards into the conclusions. The excellent Mr Mrase, head nursing tutor, pointed out early in the meeting that the only way we could hope that staff would uniformly live up to expectations, is to make those expectations explicit in the standards to which we should be working. Hooray. They will be written by next week.

Perhaps I should feel a little more guilty than I do about being an (admittedly charming and likeable) European swanning in and telling everyone what to do. I excuse it partly because I try to disguise it, with a subtlety akin to Mike Tyson asking you if you might want to let him go ahead of you in the queue, or would you prefer never to walk again. But also, I am pushing on an open door. Many people are ready for making Berega as good as it can be, and are relieved that an outsider can come and take the blame for letting in the wind of change.

There is much that will not change quickly, and perhaps does not need to. The Mount of Olives behind the theatre block will still flap with the recently washed apostles hanging on the line. The chickens will peck at the bits of food left by the relatives who camp make-shift in the hospital quadrangle. A waiting mother will still cook ugali porridge in an old iron pot on an open fire outside the waiting mothers’ hut.

But at least she is waiting here, not somewhere out there, in that humungously huge country. At last, she might reasonably expect that we are working towards making her childbirth journey safer than it has ever been.

But as I look out from my house on the hill to the distant cars on their way to Dodoma, it strikes me that it is a long, long road.