For reference: EMBRACE - 20th November version

15. EMBRACE - 20th November version

For the purposes of telling the story to posterity, I think it will be good to publish each major update of the Grand Plan as it emerges, without taking down the previous version.

In this way we can have shown how our thinking developed.

I imagine that there will be many more versions. In the end, when the ship founders on the rocky shores of a much better place, we can take the timbers and build a house. 

EMBRACE

(Empowering Mothers & Babies to Receive Adequate Care & Equality)

Berega Hospital & Communities of Mnafu & Tunguli

Development Plan for Maternal, Child & Reproductive Health

The inter-connected problems

Berega Hospital serves a vast and inaccessible territory of rural Tanzania with a population of 217,000. There are 8,500 births/year, of which only 1000 occur in a health facility. Nearly 1 in 100 women die in each childbirth. Many more suffer drastic chronic disability, such as vesico-vaginal fistula, (VVF).

Rural areas have a particular problem, made worse by the lack of education, lack of empowerment, and lack of access to birth control. More than 80% of the population live on less than £500/year. (In Europe, the figure is less than 2%). As a result of poverty, severe under-nutrition is common. Up to 10% of children do not reach their fifth birthday. Malnutrition is a vital component of the mortality, because of its effect on reducing the capacity to resist illnesses such as diarrhoea, meningitis and pneumonia.

Berega provides the only Comprehensive Emergency Obstetric Care (CEmOC) facility – ie capacity for caesarean section – for 7,000 sq km of territory. There are only two tar roads. Most other roads are impassable in the rainy months, and in the dry are only negotiable by expensive and dangerous three-person motor-bike rides, (comprising for instance a driver, a labouring woman, and a carer/blood donor). Even for those few who live near the main roads, travelling to any other CeMOC facility is both unaffordable and impractical, (70km to Kilosa; 110km to Morogoro; 180km to Dodoma).

The Vision    

The vision is for trained Community Health Workers (CHWs) to reach out, initially to the isolated communities of Tunguli and Mnafu, working with the Traditional Birth Attendants, (TBAs), Village health Workers (VHWs) and village leaders, to develop a systems for managing  childbirth, family planning, immunisation, child nutrition, and chronic conditions (eg malaria, anaemia, diarrhoea, TB, infestations, & HIV). CHWs will also help improve collection of information – eg demography, birth rate, etc.

In the process, we hope to influence the social order, by empowering women at the centre of the community development process.

Partnership – the interconnected solutions

The project is a collaboration between Berega Mission Hospital; a community development charity, (Hands4Africa); a Berega development charity, (BREAD); a Berega charity with a special interest in Tunguli, (Mission Morogoro); and a high-profile international women’s charity, (Ammalife), which has led key research. EMBRACE is a ‘sister-project’ within Ammalife.

Many recent visits to Tanzania have been made by UK and USA stakeholders, with several two-month stays at Berega.

Principles of the approach

Key features of EMBRACE, based on high-quality research, are:

·         collaboration between agencies

·         community participatory learning and action

·         training of CHWs, local women, VHWs and TBAs to take lead roles in community health and development

·         improved: maternal and child health; transport; primary care; data; family planning; and education of women; and

·         recurrent evaluation to learn lessons, to build on success, and to limit undesired outcomes

The proposal is based on local need and perception. EMBRACE will initially concentrate on building relationships by and through education of local women leaders: Community Health Workers, Village Health Workers and Traditional Birth Attendants, (CHWs, VHWs & TBAs).

Meanwhile, H4A will address transport and community meeting facilities.

The main deliverables at the first year are consensus and access to safe birth care. Thereafter, women & children’s health and community development will progress hand-in-hand.

In the hospital, a new set of agreed standards for maternity care will be bedded in, so as to ensure that those women arriving will be dealt with appropriately. Meanwhile, expanding the capacity of care-giving will be addressed by getting ready for the training of front-line ‘medical’ staff, the Clinical Officers, (COs). COs will meet the primary care needs of women and children both in the hospital and in the community – education, family planning, antenatal care, chronic ill-health & nutrition.

What will actually happen:

Phase 1. Establish a foundation    Phase 2. Build on it

Phase 1: Foundation Project: Build Relationships, Information and Infrastructure

Mnafu: learning from Tunguli:

There will be a lag phase in Mnafu before CHWs can begin the process of engaging TBAs and VHWs, for four reasons:

·         The hospital will need six months to bed in its standards and to increase capacity before it is ready to accept the extra influx of mothers

·         A purpose-built facility in the community would enhance the possibility of putting women at the centre of community development

·         This will also allow overnight accommodation – an important facility for visiting staff, particularly in the rainy season

·         Transport solutions are expensive and organisationally difficult to set up, but need to be active as soon as women are being offered emergency transfer to hospital

For this reason, the CHWs will sharpen up their community engagement process by first approaching the village of Tunguli. Tunguli already has a clinic – the only peripheral clinic in Berega’s territory – and already provides comprehensive primary care and basic childbirth facilities. Despite this, the large majority of mothers consult TBAs rather than the clinic. Furthermore, it is far from clear that the presence of a clinic translates into reduction in maternal and child mortality. We need to know the data on this, as well as understanding the possible reasons.

CHWs can therefore be trained to engage with TBAs, VHWs, the women themselves, and community leaders, to explore the possibilities of improving the system. Once EMBRACE Mnafu is ready to begin, the CHWs can transfer the learning from Tunguli to Mnafu.

Phase 1 in Mnafu:

Based on evidence of simple, workable solutions, the charity Hands4Africa will develop the transport system, including drivers, fuel, and vehicle maintenance, for adequate emergency transport in labour.

Additionally, they will build a health / community facility (using their high-quality compressed-earth technology.

At the same time, they will begin building the partnerships for Phase 2, which will include development of agronomy and education.

When the transport and building are sufficiently advanced in being delivered, CHWs will begin to engage with the community, building on lessons learnt at Tunguli.

Phase 1 in Tunguli:

Led by Berega’s maternity lead, Dr Abdallah MPH, the EMBRACE Foundation Project centres on community mobilisation and participation. Trained CHWs will engage with community leaders, VHWs, TBAs, and mothers, to examine their problems, ideas, potential solutions, and priorities in relation to pregnancy and childbirth; nutrition; family planning; immunisation; and chronic disease.

Their role in the six months will principally be the gathering of information, and the establishment of partnership. Amongst other duties, they will need to:

·         Meet village and school leaders and establish credibility and shared purpose;

·         Meet mothers and hear their story, and learn about their perceived needs;

·         Meet TBAs and learn of their practices, their concerns, and their ideas;

·         Meet Village Health Workers (VHWs) and discover what records and registers they           keep, what the problems are, and what their thoughts are on solutions and priorities. Where there are no VHWs, the CHWs could help in establishing them.

·         Discover what currently happens when there are problems in childbirth;

·         Assess other health issues relevant to health and well-being of mothers and children, such as malnutrition; family planning; HIV; STDs; TB; & Malaria

·         Discuss with the appropriate people about systems for ‘Road to Health’ charts, in particular for monitoring growth and immunisations in pre-school children. This would, in the fullness of time, work alongside a mature schools health programme for children of school age.

·         Attempt to obtain raw data on rates of death and serious complications, and try to enhance future collection of such data;

·         Assess the current frequency of attendance of women from Mnafu (and environs) to Berega, and determine what problems they come with, and what outcomes currently occur.

At the same time, as this is occurring, the charity Mission Morogoro will provide transport solutions for the established clinic at Tunguli, including the provision of an adequate vehicle for emergency transport in labour. This solution will include drivers, fuel, and vehicle maintenance.

This transport upgrade will not significantly increase the burden on Berega, as women already are transferred from Tunguli. The quality and reliability of transport will however be significantly improved, and this can be used by EMBRACE to mark a new era of engagement, and therefore to enhance the CHW work.

Phase 1 in Berega:

At the same time, the hospital will be working to implement a new Charter of Standards, to prepare it for the future influx of patients. This will include a two-month visit of a consultant obstetrician, with planning for follow-up visits; plus a programme of on-site training and inspection which will particularly include:

·         recognition of sick patients

·         emergency kits, and

·         reflective learning.

With regard to children, Phase I needs to concentrate on:

·         Emergency Triage Assessment and Treatment, (ETAT), which involves the recognition of sick children, and appropriate management, especially in the first 48 hours;

·         ward protocols for the Children’s ward and the Premature Baby Room, to include screening for and treatment of malnutrition (and any underlying causes), as well as routine daily feeding of children;

·         the initiation of Road to Health charts for those under-5s that do not have them.

Phase 2: Building on the foundation:

Phase 2 in Mnafu: Primary care; Access to CEmOC; Education, Agronomy

Having established the relationships, and understood the community perspective, CHWs will work with and train TBAs and VHWs, to bed in safe childbirth solutions, including bringing selected women into Berega for birth.

After successful childbirth within the scheme, and return of the woman and child to the community, CHWs would try to enhance breast feeding, family planning, immunisation, growth charting, under-5s nutrition, and prevention and treatment of diarrhoea, malaria, worms, and other chronic conditions. This would be centred at a purpose-built health and community facility. Healthy mothers and babies would encourage other women to follow the same path.

Once the purpose-built community facility is functional, and indeed whilst building is happening, H4A will be negotiating with the community to develop its agronomy. This will have the dual effect of creating income, and providing food.

They will develop transport solutions, based on experience and evaluation.

As these developments are settling in, the ultimate goal for H4A is to help the community to build and staff a school. Not only will this provide health through education, but also it will eventually provide educated school-leavers who can come back to the community after training as, for instance, health and development professionals.

Phase 2 in Berega: Expanding hospital capacity

In Phase 2, Berega will expand its School of Nursing to train both Clinical Officers and nurses/midwives. COs can deal with childbirth, family planning, and treatment of disease.

This will involve a significant building programme, to include classrooms, accommodation, offices, and outpatient department expansion. This is made cheaper and higher quality by H4A’s compressed earth building materials technology, which is already in situ.

CEmOC facilities at Berega will be brought up to standard, in particular in relation to caesarean section. The hospital standard of a decision-to-readiness time of 30 minutes maximum for urgent CS will be monitored and the findings discussed, with ongoing modifications made in the light of experience.

Both for the development of CO training faculty, and for the oversight of the clinical work, there will be regular visits of senior staff from the UK and elsewhere. In particular, the maternity services will be overseen by a consultant obstetrician on site for at least two months every year.

SMART Objectives for The EMBRACE Project

Summary objectives for the end of three years

In the community:

1.    Women in key roles – Mothers, CHWs, VHWs, TBAs – will be influential in driving social, health, educational and economic development

2.    There will be good local access to antenatal & primary care, and systems for referral of women and children with serious and/or chronic disease

At the hospital:

3.    Clinical Officer training will be have begun, with adequate recruitment, accommodation, curriculum, faculty and supervised placements

4.    Data systems will be strong, and the impact of this project on the community of Mnafu will have been measured and evaluated, learning lessons

5.    Hospital standards will be regularly measured and reinforced, which will show that maternal and perinatal mortality will be acceptable and falling

Expanded objectives, looking forward to five years

At 6/12:

Two trained female CHWs will have forged links with all key community leaders, key individuals, TBAs, VHWs, and any other significant players the Mnafu community.

A report will be written on the findings from the experience gained by the Team at Tunguli. Lessons will be learned that can be transferred to Mnafu. A pathway will be agreed with TBA's and VHW's for bringing to hospital those mothers who are likely to experience difficult births.

A transport solution for this will be in place.

At 12/12:

In the community, plans will have been agreed which include:

·         acceptance of key roles of women – especially VHWs, TBAs, mothers and teachers – within the body which determines the development of the community

·         training of TBAs as part of triaging pregnant women

·         referral pathway, transport and economics of pregnant women needing hospital

·         training of VHWs, including in establishing accurate demographics and records

·         systems for improving health of mothers and children by access to primary care and antenatal care

·         provisional long-term plans for transport, education, and a maternal /child / family planning health facility

At the hospital:

·         the plan for CO training will have Government approval and a start date

·         inspecting the implementation of the Charter of Standards for care of mothers and under-fives will be happening at least weekly

·         systems for measuring the impact of the project on the Mnafu community, and their uptake of services at the hospital will be in place

At 2 years

In the community:

·         empowered and trained women will be involved in normal decision-making in the development of the community

·         trained TBAs will be following agreed pathways of care for pregnant women

·         pregnant women needing hospital will be arriving there readily, reliably and affordably in sustainable transport systems

·         there will be appropriate action towards the goal of local access to antenatal care, family planning, immunisation, & growth charting; and systems for dealing with malaria, infestations, diarrhoea, and malnutrition, and for referral of women and children with serious and/or chronic disease

·         trained VHWs will be directly and deeply involved in maintaining the health of mothers and under-fives, including in the complete and accurate recording of key data and demographics

·         long-term plans will be in an advanced state of readiness for transport, education, enhanced prosperity and a maternal /child / family planning health facility

·         At the hospital:

·         CO training will have begun

·         Monthly reports on maternal and under-fives health will be produced, based on accurate and complete data, as well as regular inspection against the Charter of Standards

·         These will demonstrate acceptable levels of care

·         Three-monthly reports on the access of the Mnafu community to hospital-based care will be produced, based on accurate and complete data

·         These will demonstrate an appropriate uptake of primary and secondary care, with follow-up of healthy women and children in the community

·         Transferrable lessons will have been learned for similar development of other isolated and /or needy communities

At 3 years

In the community:

·         The two-year goals will have been revisited and implementation will have been strengthened where needed

·         there will be local access to antenatal care, family planning, immunisation, & growth charting; and systems for dealing with malaria, infestations, diarrhoea, and malnutrition, and for referral of women and children with serious and/or chronic disease

·         long-term plans for transport, education, and a maternal /child / family planning health facility will have begun implementation, including at least the commencement of the building needs

At the hospital:

·         CO training will be have completed its first year, with adequate recruitment, accommodation, curriculum, faculty and supervised placements

·         Data systems will be strengthened

·         Maternal and perinatal mortality will be at acceptable levels, and falling

·         Transferrable lessons will have begun to be implemented for development of other isolated and /or needy communities

At 5 years

In the community:

·         Women in key roles will be influential in maintaining the drive for social, health, educational and economic development

·         There will be good local access to antenatal care, family planning, immunisation, & growth charting; and systems for dealing with malaria, infestations, diarrhoea, and malnutrition, and for referral of women and children with serious and/or chronic disease

·         A maternal /child / family planning health facility will be built and operational

·         Systems for local education will be implemented

At the hospital:

·         CO training will be have completed its third year, (with its first graduates), with adequate recruitment, accommodation, curriculum, faculty and supervised placements

·         Data systems will be strong

·         The impact of this project on the community of Mnafu will have been measured and evaluated, and will demonstrate that the project has brought about substantial reduction in mortality and severe morbidity of mothers and under-fives

·         Hospital maternal and perinatal mortality will be at acceptable levels, and falling

·         Transferrable lessons will be being learnt from the development of other isolated and /or needy communities

Management and accountability of funding

The funding of this project will be separate from the hospital funds, and ring-fenced such that it can only be used for the designated purpose. The health aspects of the project will be housed in the UK maternal health charity Ammalife¹¹, who will hold the funds, (without charge), and who will expect accountability for their deployment.

Deployment of health and health education aspects of the project will be managed through a cooperation between Berega Hospital¹² Management Team, and their charity partners BREAD¹³. The BREAD project management team visit Berega at least once a year, to oversee the implementation of charitable works.

The community development and transport aspects of the project will be under the aegis of the American charity, Hands4Africa¹⁴, who have a long history of extraordinary success in the development of education, transport, building and agronomy in Berega. They are self-funding.

Collaborators

All partners are in agreement, and fully on board with this project plan:

Rev Isaac Y Mgego

Director, Berega Hospital

Prof Arri Coomarasamy

Trustee and Founder, Ammalife

Dr. Brad Logan

Founder and Chief Executive, Hands4Africa

Gary Mann

Chair, BREAD

Dr. Laurence Wood

Obstetrician & Project Activator

Tony Mortimer

Chair, Mission Morogoro

Key evidence for the strategy includes:

(* = evidence contributed to by Ammalife)

·         The recent census quantifies the problems³.

·         Local, trained CHWs (& VHWs) are central to the solution⁶.

·         The model of VHW training is critical¹⁰.

·         *Women’s participatory learning and action is highly effective¹⁵.

·         *Training of TBAs really really helps¹⁶.

·         *Clinical Officers are a vital part of the solution. Not only are they effective in primary care but even in complex maternity interventions¹⁷.

·         *Transport solutions are both vital and deliverable¹⁸

·         Christine MacArthur is currently trying to ‘manualise’ engagement with TBAs

References

1.    http://data.worldbank.org/indicator/SH.STA.MMRT/countries

2.    http://data.worldbank.org/indicator/SH.DYN.MORT

3.    http://www.nbs.go.tz/takwimu/references/Tanzania_in_figures2012.pdf

4.    http://en.wikipedia.org/wiki/List_of_countries_by_percentage_of_population_living_in_poverty

5.    http://www.ihi.or.tz/projects/the-connect-project

6.    http://1millionhealthworkers.org/2013/04/15/tanzania-hosts-global-one-million-community-health-workers-campaign-forum/

7.    http://www.frontierus.org/documents/FREP_Reports_2012/FREP-Community_Health_Worker_Care_Coordination.pdf

8.    http://www.cdc.gov/dhdsp/docs/chw_brief.pdf

9.    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3343233/?tool=pmcentrez&rendertype=abstract.

10.  http://www.ncbi.nlm.nih.gov/pubmed/2363189

11.  http://www.ammalife.org/

12.  http://actmorogoro.com/HEALTH.html

13.  http://www.bread-trust.org.uk/index.html

14.  http://www.hands4africa.org/

15.  *http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)606856/fulltext

16.  *http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)606856/abstract

17.  *http://www.ammalife.org/wp-content/uploads/2013/06/BMJ-ClinicalOfficers.pdf

18.  *http://www.ijgo.org/article/S0020-7292(13)00256-7/abstract

15. Grandma’s Juice

15. Grandma’s Juice

16^th December 2013

Words. In this blog, I use them to depict the dire reality of life in a remote part of Africa. But the tragedy unfolds there, whether or not I describe it. (Just like when I am sent to do the shopping: what I buy is going to be wrong, whether or not my wife gets the chance later to give me personal feedback. What’s the difference anyway between fresh crème and crème fraiche? A trifle, surely?)

Anyway, it is the reality that matters. The words can get in the way. The situation in Berega, (as in many other parts of the world), is bursting with meaning and import and consequence, but all you get are words. My words, in the case of Berega. Can they be enough?

My 21-month grandson, already a master of the inadequacy of words, illustrates the point: “Man-ma’s juice is hot!” ‘Man-ma’s juice’ was my cup of tea. This was Freddie’s first full sentence, at the start of that wonderful decade between not being able to speak, and not wanting to. It was so cute that we have not had the heart yet to begin the rigid programming of mind which The World demands of its inmates.

The sentence was nevertheless wrong in every way: He calls both my wife and I ‘Man-ma’, a corruption of ‘Grandma’, but I am in fact ‘Dandad’. It was not juice, it was tea. And although he was correct to infer that beverages made with boiling water can indeed be hot, this particular cupful was at best tepid. The nub is this: Did we pull him up on the inadequacy of his descriptive powers? (“You foolish child! I am your male antecedent; a beverage by definition cannot be a vegetal extract; and this specific cup was barely above the melting point of caesium at atmospheric pressure!) Yes, we did.

No, not really. Instead we boasted about the cleverness and cuteness of little Freddie to all those who have not yet got into the habit of crossing to the other side of the road when they see us coming with a smug look on our faces, and a finger fumbling for the photo album on the phone.

Freddie also deploys many other teddy-cuddling cutenesses. My favourite is his tendency to use ‘No’ to mean both ‘no’ and ‘yes’:

(“You poor little baby, you are so hungry. Do you want some food?”

“Nooo-oooo-sob sob sob-ooooo”

“Here it is then…”)

(By the way, these verbal faux pas are presumably designed by Nature to endear us to what are otherwise machines for turning anything edible into poo. “I’m weally weally hungwy” is far more likely to induce a beleaguered parent to stump up a sausage than: “Mother, the hour of my repast has surely slipped into the abyss of forgotten dreams. Ah! The sweet sound of sausages, that breathes upon a bank of bacon, stealing, and giving odour!” Without the endearing mistakes, they weally would be hungwy. Perhaps the highly intelligent Cro-Magnon man died out because their children’s first sentences were particularly annoying – “Oi! Pig-face! Get me grub! Now!!!”)

The nub is this: words are important, but alone are not enough. Freddie, like rural Tanzania, is bursting with meaning and import and consequence, for instance about the potential danger of Grandma’s Juice or Bad Roads or High Blood Pressure. The expression of this does not do justice to the reality or the understanding.

This last month has been full of similar inadequacy of expression. My time has been split between getting harmony and getting money. The various charities working for Berega’s future need to harmonise, and that means having a collective plan that says clearly what we are all trying to do; how; and by when. Meanwhile, grant applications demand a certain practised style in the use of words: ‘The evidence-based intervention propounds a setting-specific self-sufficient synergy between the inter-agency evaluative action objectives and the … er … chickens’. (Often I run out of steam towards the end of these sentences, which is why I am not a very successful grant-raker.)

Words, words, words, but what of the mum who does not return home to her children? Does ‘1% maternal mortality per childbirth’ convey enough of the sadness? Does it capture the empty, desolate weariness of the 6 and 8 year old sisters as they struggle next day to find water and carry it home? All hope of schooling now lost, how will they themselves survive?

I feel the inadequacy, then, as well as the usefulness, of having adopted a catchy title for what we are trying to do: ‘EMBRACE’ – Empowering Women to Receive Adequate Care & Equality’. Thanks to Howard and Paul, we now also have a logo, a flyer and a standing order form. A facebook page is being set up. Twitter will follow. Thanks to Ammalife we have a Mother charity, and thanks to Debbie and Blanché, a global following amongst the world’s pearly queens. Thanks to lots of you (but not enough!), we have some money. Thanks to BREAD, Hands4Africa, Mission Morogoro, Isaac, Abdallah, the Diocese of Worcester and others, we have a plan.

What is needed now is somehow to convey what is really happening there, and how it is changing. What goes right, what goes wrong. What helps, what hinders. Which sentiment, softly spoken by the right person to the right person, will have the power to stimulate a new understanding and a new expectation in this beautiful and untouched part of Africa.

Words will not be enough. Let me think, over Christmas, how the story of this next year can best be told. Meanwhile, I hope that the story of a very successful Childbirth brings joy to your world, and to those you share it with.

Laurence

xxxxxxx

By the way, apologies for the very late arrival of this blog. Life has been full, in many ways. If in future you would like to know when a blog is being posted, please email me, and I will set up a Wandering Nib Club.

email.lozza@gmail.com

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.

Looking for a dual carriageway

Gairo Main Street seen from the Rusty Axle Corral

Tanzanian motorway network. Most of the lines are rivers.

Dodoma metropolis, from the hill above

Katibu in Dodoma market, deciding which orange

The apostles being summoned for a cesarean

It's a long, long road.