22nd September 2013
In the six weeks since I left Berega, two mothers have died in the hospital. One young woman was unfortunate enough to develop eclampsia at 28 weeks of pregnancy. Pre-eclampsia, (the stage before eclampsia), is a malignant type of high blood pressure, which eventually picks off the organs one by one. Once the brain begins to be targeted, convulsions set in, and the disease is now called eclampsia. Treatment to hold back the fits and blood pressure can provide a window of enough hours to deliver the baby, and then to get on with bringing back the mother.
The worst eclampsia cases often occur at a premature gestation, and in the UK, the obstetrician must weigh the whole situation in deciding the timing of delivery: here in the UK, delivering a baby at 28 weeks results in a 90% chance of it surviving. In Berega, the figure is zero. No-one will have time and emotional energy, however, to grieve the baby: the mum's life is the priority. Her brain, liver, kidneys, lungs, heart and blood have to be coaxed back to normality, in a part of the world where the nearest they get to Intensive Care is a blood pressure cuff that works, used by someone who knows what to do with the results. Even the IV fluids are home-spun and the 'giving sets' erratic. In rural Tanzania, many do not make it, and nor did this terrified woman or her baby.
Saving a woman's life once eclampsia has set in is like trying to prevent death from lion attack - it is only hard if you did not see it coming from a long way off. Eclampsia is usually preceded by weeks of symptom-free high blood pressure. This woman would have been fetching her water and cooking her ugali without ever being aware of the silent predator that stalked her, nor of the tragically few days she had left to live.
I paint the picture in all its poignancy, to highlight the harsh injustice of Nature in the raw. The reason that Chagongwe and Mnafu and Maguha and Tunguli have two-hundred times worse maternal mortality than Estonia is not because the latter has an ITU in every village. They do, however, have proper drips, and blood pressure cuffs, and people who know what to do with them. And roads. And systems of transport thereon. Preventing death from eclampsia is as simple as a village health worker (VHW) doing regular blood pressure checks, and referring in anyone whose BP is above a certain level. When I look back on my choice of career, this was a central influence: turning potential tragedy into joy by such easy means.
The other death was also deeply harrowing, and I will not give details. Suffice it to say that the problem was the combination of obstructed labour and haemorrhage, which conjunction is a grim reaper of young women in rural Africa. Again, in the final stages, the solutions are often beyond the resources of a hospital like Berega, but earlier on much can be done. Seeing the woman before the labour became obstructed would be a big advantage, and once more a VHW has a role in encouraging waiting at the 'waiting mothers house' in the hospital, when labour is approaching. This would especially apply to those for whom a troublesome labour might be anticipated - for instance a slim sixteen-year-old in her first pregnancy. Better still is for her not to get pregnant - but where does an uneducated village girl even get the knowledge about contraception, far less the methods. Once more, VHWs can provide simple solutions.
It was a great joy, then, to help steer Berega's community development plan for mothers and children to its next stages. (see the updated blog post.) This began with triple and quadruple checking with the hierarchy at the hospital, and their advisors, that we have indeed captured their own vision, and that this is not something being done to them. Their response has been an overwhelming and heartfelt supplication that we might continue to make progress together towards the vision that they themselves set, (by candlelight in evening meetings in the mission house, was it just two months ago?) The repetitive listening process is a powerful instrument for change: sometimes it is only on the fourth reading of what will become our catechism, that we spot the flaws and subtext and difficulties. The major changes made so far reflect the importance not just of delivering babies safely, but of trying to prevent them becoming one of the one thousand under-fives that die in Berega's territory annually.
Success will depend on bringing together as many as have a part to play. Three of the key agencies at the UK end are the Diocese of Worcester, the charity BREAD. and the charity Mission Morogoro. The latter two have as their entire raison d'etre the development of Berega, although coming at it from different angles, different parts of the country, and different funding sources. (Worcester Diocese has a wider brief of course, with the cure of the souls of half a million Worcestrians never something to be underestimated.) At the meeting we shared our different takes on how we might help in the future - and there are as many different takes as there are different needs. Achieving focus, unity of purpose, and division of labour is worth all the effort we will put into it. When obstacles inevitably arise, what controls our ability to remove them is not so much our power, as our combined determination.
Meanwhile, the Charter of Standards at Berega Hospital is being translated into Swahili, with the intention of giving a copy to each and every member of staff. Given that this strategy has come from the hospital management with no external influence other than initial catalysis, I am heartened to know that they really mean business.
Hands4Africa is another major player, and Brad has been honing down his thoughts and sharpening up his tools. We hope that H4A will be a major influence in working towards transport solutions. In this week alone at Berega there have been three major road traffic incidents, the biggest being twenty-five admissions in various states of broken-ness. They all survived. When the rains come, it gets worse.
Of course it is not only in rural Africa that such accidents occur, and blog readers will be devastated to know that I myself was unceremoniously unshipped from my bicycle on my first outing since my return. Coming down a hill towards a gate across the cycle path, my version is that I swerved to avoid a mother of quads, and, in a feat of acrobatic heroism, flung myself and the bike into a paratrooper shoulder-roll when the most vulnerable of the quads went back to pick up her dolly. My fellow cyclists' version is that I was going too fast, and sailed over the handbars like a flying frankfurter. Mother Earth eventually broke my fall by smashing my helmet into my head, in the process taking two inches off the length of my neck. Whichever version you care to believe, Mother Nature comes out of it as being hard and uncompromising. She needs us to take her in hand.
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