11. Us versus Mother Nature

11.  Us versus Mother Nature
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.

10. The Emaciated Mzungu Memorial Trench

10. The Emaciated Mzungu Memorial Trench
8th September 2013

Today it is raining, for the first time since my return. (Was that really three weeks ago?)

“That’s not rain”, a Tanzanian Crocodile Dundee would say, “This is rain!”, unleashing from behind his back a vast torrent, whence river and road became indistinguishable. Twice a year in Tanzania, the oceans and lakes and jet stream and sun get together, and for a few months fill the skies with surprised rivers, who had expected to be more terrestrial. They very quickly establish their fluvial rights, however, and pour down to earth, rushing in every direction in search of their familiar banks.

In the process, they make something of a mess of the roads. Months of sun will have hard-baked the dirt roads, but also fractured them. Then stones below the surface get dislodged by over-burdened traffic, and the fissures get wider. The more traffic on the road, the more the need for its integrity, but, ironically, the more the crunching and the cracking. Thereafter comes the rain, and the grateful river of water surges down the rifts, dislodges future silt, and leaves behind swirling furrows crossing the roads this way and that. During the rain, the dirt roads are all-but impassable, but when the sun comes out, it serves to dry the furrows into ruts and bumps that challenge even Land Rover suspension. And there aren’t many Land Rovers.

The front drive leading to our mission house was a case in point. The house, (as you will by now have seen on You-Tube), is tolerably comfortable, and the sitting room looks out over the steep valley to the hills beyond. Many times I have sat on the verandah, gazing emptily towards the dry river bed far below, wondering what to say in the next blog, but distracted by tantalising thoughts of distant sausages. It’s a beautiful valley, but as a result of its steepness, the rain leaves the front drive less a road and more an assault course. Being circular, the rain cannot simply run down it, and so reluctantly hacks it into furrows, as it charges down the hill towards a tumultuous reunion on the valley floor.

Water, however, despite its destructive capacities, is very biddable. It only turns your front drive into a ploughed field because it is trying to get out of the way, and if you give it the option of getting out of the way more easily, it readily accepts. Thus the Emaciated Mzungu Memorial Trench.

The story went like this: More than a month in to my stay in Berega, I was a wizened, puny vestige of my former self, with no opportunity to exercise, (other than lifting an occasional heavy pan of inedible yellow things, in order to discard them on the compost heap). On our visit to Dodoma, however, I saw a pick-mattock for sale, and pounced on it. A mattock is a beast of an instrument: Where a hobbit would use a hoe, a cave troll would use a mattock. It goes without saying, of course, that a pick-mattock is better for trench-building than a grubbing-mattock, because the pick-end enables removal of bigger rocks, whilst the mattock-end can hack out a trench, oblivious of roots and rubble. The entire tool, with handle, weighs about twelve kilogrammes. Having, with the pick, wheedled any stones out from the path of the mattock head, you then unleash the mattock onto mother earth, gashing a deep furrow in her flesh.

At the top of the drive, I planned the route that the water will take when the first rains arrive in November. Passers-by on the road stopped to admire the efforts of the emaciated mzungu, manfully standing up to the might of Nature, and pummelling the would-be trench into existence. Being out of condition, I had to rest after each blow. I would have rested half way through each, had it been an option. By the end of two hours, a few inches of trench were already demonstrating their proclivity, by directing a litre or so of mzungu sweat down the hill. From the boys of the village, flocking incredulously around, a polite murmur of what I took to be awed appreciation sniggered between them and the gathering mosquitos.

The path of the trench I sketched out by two parallel lines running down the side of the drive, and onto the thirsty lawn below. The first half-metre, mattocked to perfection, is a veritable Suez. Sadly, however, I did not get much further with the trench before I left Berega, and Sion has now taken over. As a result of his blow by blow assault on the un-mattocked section, an Emaciated Mzungu Memorial Trench is now being grooved into the erstwhile random surface of Africa.

It will be completed. We know what we want, we know where we want it, and we have begun. When the rain begins to fall, it may be that we will need to take account of the way water naturally flows, but thereafter it will flow with a sense of purpose, reinforcing the trench more deeply with each downpour. As the perceptive will have noticed, I have just managed to ooze my way into a relevant metaphor: Although I am now back with my own tribe, the journey to safe childbirth for future mothers in Berega’s territory has begun. Careful hands are now deepening the commitment and purpose and direction. Things may unfold differently to our plan, but perhaps not by much. There is no going back to the random inefficiency of the past. It will be completed.

Beautiful examples of the irreversibility are the inspiring activities of Kofia in Guildford and environs. Their thriving website is the hub of both fundraising and spreading of awareness, but I particularly love the fact that they have knitted nearly 500 hats for Berega babies – and arranged a means of getting them there. Part of the vision is that once babies have been delivered safely, (which involves staying warm), they will continue to thrive when they go back to the villages. We want to follow up women back in the remote parts, and help ensure that their babies grow into healthy children. Having a Kofia hat might become the hallmark of a new era of health for this new generation of babies.

Meanwhile Brad, from Hands4Africa, is enthusiastic and inspired by the idea of a combined assault of community development and a community-based maternal/child health programme in Mnafu. It will allow women with no current realistic access to health care to have their babies in safe settings, and to raise their children without the expectation that 10% will die. The plan will now be fleshed out, having now decided that in the first instance, the priorities are bespoke transport, and a health facility at Mnafu. Economic growth and education will follow, in partnership with the development of systems for safe childbirth and healthy under-fives.

The Diocese of Worcester has completed a hugely successful sponsored climb of Kilimanjaro, raising thousands of pounds. A dozen or so people, some of whom had suffered altitude sickness whilst training on the Malverns, nevertheless managed to conquer the mountain. It was salutary to note, when flying home, that the mountain top was nearer to the plane than it was to the plains. I would have paid thousands not to climb it, so utter congrats to those who even tried. Meanwhile, I have been humbled and touched by the support of friends and blog-readers; and of others whose catalysis I will talk more of next time – thank you. We are poised to make a difference where it will really count.

Meanwhile, back in Berega, progress continues. Isaac Mgego, the hospital Director, is mustering forces at that end, ready and eager to begin a new era. Last month we saw reliable electricity become ensconced at the hospital. This month, for the first time in its history, a blood bank opened. It sounds a small thing, but until now, if a woman were bleeding inexorably after delivery, we would first have had to call in a relative or a compatible donor before we could give her blood. Truly life-saving.

By the way, talking of life-saving, those following the tortuous tale of my nutritional nadirs will be delighted to know that my life is no longer in danger. I have eaten more Pork & Leeks and Spicy Cumberlands than any man’s gall bladder should decently have had to deal with. My blood pressure and waist size are creeping up nicely, and the sentinels of my liver have sent out for reinforcements. Furthermore, my exercise tolerance is beginning to build, and my legs no longer look like articulated wooden spoons. Part of the de-wooden-spooning programme is country walking, and so it was that on Tuesday we went to the Peaks, and I once again immersed myself in English countryside. In the evening, pleasantly aching from ten miles of Derbyshire tracks and trails, fields and villages, woods and rivers, steep slopes up, steep slopes down, and even some steep flat places, all leading to deep satisfaction of arriving back where we had started from, I sat in the garden of the Devonshire Arms, and got outside a home-made game pie and a pint of ale, watching a yellow wagtail hop around the stones of a fresh, lively English stream. I was very satisfied to be home.

The next day, the full English breakfast strengthened me for the shock of the bill. A night in an English inn costs more than a month’s living costs in Berega. In fact I do seem to have overdone my response to the rediscovered capacity to spend money, which I was anyway always quite good at. In Tanzanian terms, my income is like the spring rain flooding down across my life, washing this way and that in lavish exuberance. I suspect that Mis (my wife) thinks I need mattocking. 

For reference: Berega Hospital Development Plan for Health of Mothers and Children - Fourth Draft

Berega Hospital Development Plan for Reproductive Child Health

(RCH - Health of Mothers and Children)

(draft 4)

The Problem

Tanzania has one of the worst maternal mortality ratios in the world¹, mainly due to the combination of poverty, lack of education, lack of understanding of disease, long distances, poor family planning, and poor transport.

Furthermore, the rate of neonatal and child death is probably even more serious², but currently difficult to measure in impoverished, isolated rural parts of the country, where as many as 10% of children are expected to die before their fifth birthday. Chronic malnutrition contributes to almost half of these deaths.

Within this context of rural Tanzania, Berega Hospital serves a vast and inaccessible territory of approximately 100 x 70km. This area has just two tarred roads, and, according to the 2012 National Census³, a population of 217,000. Extrapolating from the national data, there are 8,500 births/year, of which only 1000 occur in a health facility.

Many roads are impassable in the rainy months, and others are only negotiable by long, expensive, and dangerous three-person motor-bike rides, (comprising for instance a driver, a labouring woman, and a carer/blood donor). Berega provides the only Comprehensive Emergency Obstetric Care (CEmOC) facility in this territory – ie capacity for caesarean section. 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).

Millennium Development Goals (MDGs) IV and V from Tanzanian 2012 census

Of particular importance in developing the health services of this area is the need to address the MDGs IV& V – Under-5 and Maternal Mortality. The national census³confirmed that the rural areas have a particular problem, made worse by the lack of education and lack of access to birth control. Women have large families, and expect some of their children to die – and even perhaps to die themselves.

The maternal mortality ratio for Tanzania in 2012³ was 454 women dying for every 100,000 live births, (ie 0.45% of mothers die in each childbirth). The worst in the world is 1100¹, (1.1%), and the best is 2, (0.002%). As the Tanzanian figure is the average for the entire country, it is likely that in isolated rural areas, the figure for mothers who die in each childbirth is nearer to 1% than 0.45%.

This means that in Berega’s territory, at least 40, and perhaps as many as 80 women per year die in childbirth. Many more suffer chronic disability, such as vesico-vaginal fistula, (VVF). VVF has a profound effect not just on the woman but on the family – she leaks urine from the vagina 24 hours/day. This makes it very difficult for her to live in the cramped conditions of rural village life, and yet the survival of the children depends on her.

The 2012 Census under-5 mortality figure for the country was 8.1%³. This figure will be a considerable under-estimation in the isolated rural areas. This compares with, (for example), 10.1% in Afghanistan², and 0.2 to 0.5% for most European countries.

In Berega’s territory, where there are 8,500 births/year, this under-5 mortality rate means that perhaps as many as 1000 of these will not reach their fifth birthday, mainly due to the combination of poor nutrition and chronic but easily treatable disease. The under-nutrition is a vital component of the mortality, because of its effect on reducing the capacity to resist illnesses such as diarrhoea and pneumonia. In impoverished rural areas, many children survive mainly on thin porridge, (‘ugali’).

In Europe, North America and Russia, less than 2% of the population live on less than $2/day⁴. In Tanzania, the figure is nearly 90%⁴.

The Vision

The vision is to reach out to isolated communities, working with the Traditional Birth Attendants, (TBAs), VHWs and village leaders, to develop a system of assessment and early referral of women with problems in childbirth. The TBA would accompany the woman to hospital.

Furthermore, Berega's outreach to these communities would work with both the TBAs and trained Community Health Workers^5,6 in a partnership to enhance ongoing maternal-child health and nutrition, eg improving child nutrition; recognition and early treatment of severe or chronic illness (such as malaria, anaemia, diarrhoea, TB, infestations, HIV); immunisation; registering families and following up the disadvantaged; and family planning. CHWs will also help improve collection of information – eg demography, birth rate, etc.

This would be happening in the context of an integrated community development driven by a planned partnership between:

· the local community;

· Berega Hospital;

· the American community development charity Hands4Africa, (H4A);

· the UK Berega charity Berega Relief Education And Development, (BREAD);

· the UK maternal health charity Ammalife;

· the Anglican Diocese of Morogoro.

The aim would be the enhancement of the transport, data collection, economy, education and facilities for currently isolated communities. A number of other charitable organisations are interested in providing start-up support, for instance the Diocese of Worcester, and Kofia.

The Strategy

We have selected the community of Mnafu to begin the programme. The aim, ultimately is to reach a point of self-sustainability in health and community development. We will only to move on to address the needs of other isolated communities, when we feel that we have learnt sufficient lessons from Mnafu, and when to move on will not reduce the prospect of Mnafu and the surrounding communities achieving self-perpetuating development.

Phase 1A: Community Base - Reproductive Child Health CHWs

At the centre of the project will be bespoke Community Health Workers, learning lessons from and communicating with similar Tanzanian projects^5,6. A team of mature, trained^,7,8,9female RCH Community Health Workers will approach the community of Mnafu. At first they will be accompanied by the Project Lead Dr. Abdallah, (who is also the Head Doctor of the hospital, and Maternity lead. He is just completing his Masters in Public Health, with a specific interest in maternity outreach in rural Tanzania). The CHWs will be recruited from staff who have worked for many years in maternity in the hospital.

Their role in the first year 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; (For the purposes of this paper, the distinction between VHWs and CHWs is that the former are villagers based in the community, whereas CHWs are health workers reaching out from the hospital¹⁰ . Nevertheless, there is considerable cross-over in the literature between the two terms.) 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.

Whilst this is occurring from the hospital side, H4A, using their own funding, would have begun their programme by enhancing the transport possibilities from Mnafu. At the same time, they would have begun the negotiations to begin food and cash-crop agriculture to the community, as well as to begin the building of a facility which in future could be used as a clinic.

Phase 1B: Hospital Base

At the same time that these beginnings are being made in the community, the hospital will be looking internally at its processes and patient pathways, to optimise the care for mothers and babies when they reach the hospital.

In relation to mothers, minimum standards of care have been set out in a hospital charter, which came from the hospital staff themselves, in order to work together to improve outcomes. An example is the 30-minute decision-to-readiness time for emergency caesarean. The entire Charter is available on the blog site.

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

When trust and partnership have been established, the next phase of work would be to begin to bring women into Berega for giving birth. Whether this were all women, or selected ones, would depend very much on the results of liaison with the TBAs. There may be local solutions to some of the problems, and these should not be ignored.

It is clear that, given the long distances and the speed with which complications can occur in labour, the ideal would be for all women to deliver in a CeMOC facility. This, however, is impractical for many years yet, and the project will explore the most suitable working compromises – which will evolve with time.

When the transfer policy is decided, one potential model is that TBAs will thereafter accompany women-in-need to hospital for childbirth. Whether they will be paid a small amount for their involvement will depend on how the plans unfold after community liaison, and will be heavily influenced by policy and evidence. Whatever model is adopted, it will need to be self-sustaining financially. There is, however, considerable scope for this, given what families currently pay – for instance for those women who transfer in using private transport, and subsequently need to pay for caesarean and /or extended stay.

When women have successfully followed this pathway, and delivered healthily in hospital, these will then become ‘flagship pregnancies’. The RCH CHWs would follow-up those women and babies back in the community, to 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.

At the same time, registration of families would help ensure that no-one was left behind and that measurement of the effects of intervention might be realistic.

The aim would be to produce a high-profile cadre of mother and babies who have survived childbirth and early child-rearing healthily. These would then encourage others to do the same.

Phase 3

Assuming an appropriate unfolding of the first two phases, the need would then arise for fully staffing the clinic facility at Mnafu, upgrading its resources and equipment, and later providing a birthing facility for uncomplicated women. The upgrade of the building would be provided by H4A, in association with the community itself. 

In relation to staffing, and in readiness for arriving at phase 3, Berega needs now to begin its application to begin a Clinical Officer (CO) training programme. In rural Tanzania, COs are the front-line staff. Having achieved a high standard and good grades in high school, student COs are trained for three years in the management of childbirth, and of all common illnesses. Clinical Officers can staff a clinic and birthing facility, and are especially taught in regard to the recognition of those patients who need to be transferred to hospital.

Not just COs but also nurses are needed for dealing with the extensive health care needs of Berega’s population. As with COs, it is important for Berega to have a sustainable strategy of training its own nursing staff. The existing nursing school (SONAB), which trains to Diploma level, recently had its first graduation but is only part-way through the staged expansion to full capacity. It is vital, then, that the growth of CO education does not impede the completion of SONAB’s plans, but rather works with it in collaboration, and enhances it.

Fundraising for building the classrooms, offices and student accommodation for this combined ‘Health Education Institute’ has already begun. There are significant set-up costs, especially in relation to buildings. The SONAB building plans will be melded with the CO training needs, to produce a composite building strategy. This will mean that the funding gap in CO and nurse education will be principally in the first three years. These costs will be considerably reduced by the existence of H4A’s already-purchased compressed earth technology, which will provide very high quality building materials at the lowest possible cost.

After the buildings are complete, fees and other income of the Health Education Institute will need to be set at a level which is self-sustaining, and which will pay for both the faculty and the day-to-day costs.

Plans are being developed for recruitment of a supplementary visiting faculty to enhance the training at no extra cost, enabling the School in future to be self-sustaining on training income.

Phase 4 – the long term vision

As educational opportunity improves for the children of Mnafu, we hope eventually to be training as nurses and COs youngsters who have come up from Mnafu schools. COs, after practising post-qualification for a minimum of two years, can then carry on and be trained as ‘Assistant Medical Officers’ (AMOs), who are in effect the doctors and obstetricians in rural Tanzania. Although the tendency is for COs to look for work in less rural settings, it would only take a few of the best students to stay on, to enable the gradual building of a motivated and locally-derived sustainable workforce. The same comments apply to senior nurses and to future educational faculty.

The cost of expanding the staff of Berega to offer positions to graduates of the School would be readily covered by the increased income related to numbers of patients treated. In maternity alone, there are more than seven times as many women currently delivering in the community as deliver in the hospital.

Once CO training is established, and both hospital staff and training faculty are self-perpetuating, it raises the prospect of future expansion of the School of Health, for instance to increase training of laboratory workers or CHWs.

The long-term vision is to have an economically viable community, with good health and educational facilities, and a lattice-work of COs, CHWs, VHWs and TBAs working within a well-oiled mechanism for early transport of the needy to high quality high-tech facilities at Berega Hospital.

As soon as the lessons had been duly learnt from Mnafu, Berega could then begin outreach to another community in need, until all of the isolated communities have been reached.

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

For reference: Some video clips!

At last back in the world of fast internet, I can give you some moving pictures! The road to Mnafu shows the beginning of the road from the hospital. Mnafu is about an hour further on.

Road to Mnafu:  http://youtu.be/cDGP2GJRWuA

http://www.youtube.com/watch?v=cDGP2GJRWuA&feature=youtu.be

Hospital House: http://youtu.be/n84o3Mztf9o

http://www.youtube.com/watch?v=n84o3Mztf9o&feature=youtu.be

Berega Hospital: http://youtu.be/D9YBOYn10FA

http://www.youtube.com/watch?v=D9YBOYn10FA&feature=youtu.be

Sion Bird: 

http://www.youtube.com/watch?v=M0MYNAN98aI&feature=youtu.be

09. The tragedy of the hedgehogs

09. The tragedy of the hedgehogs

25th August 2013

Just over a week ago, still full of Africa, I landed on an unaccustomed green island, a bit befuddled and bemused. Hordes of my tribe jostled and jabbered. Then, like ducklings crossing a road, they self-organised into a wavy line to negotiate passport control. They seemed instinctively to know who had arrived first, and this unwritten law wielded an awesome power, woe-betiding any would-be self-advancement. It felt strangely foreign. At the baggage carousels, I tried to find my previous impatience, but it never appeared, presumably lost in transit. I grappled my 40kg of luggage from the belts, trying to remember why I had brought so many pairs of trousers and yet only two legs.  

Then, as is customary for the English, nothing to declare, and so through to England. Aaaaaaaah! England!! Thanks for waiting for me. A fresh breeze. Damp, leaf-green trees, and vivid, bright green grass. Why would I have missed grass? It hadn’t missed me. I am struck first with gratitude to be back, and then with curiosity as to why it should matter so. Wasn’t the weather better in Tanzania? Wasn’t the pace of life less frantic? Weren’t even strangers there kind and welcoming, with a shared chuckle at my mangled Swahili? Why would I prefer a cloudy sky with a hint of rain? Do Tanzanians arriving home have the same sense of grateful relief at the first hot whiff of Dar Es Salaam dust, or the first iron taste of cauldron-cooked ugali? What is home, that it beckons so powerfully? I had only been away two months, and you could get more than that, (if the magistrate were in a bad mood), for vexatious tort in fief. I am part of the first generation of a tiny proportion of humanity never to have suffered enforced and prolonged absence from home, and I don’t think that I quite appreciate my good fortune.

I climbed into the back of the car, revelling in the tarmac surface, the lack of roll-bars, and the absence of dog, cow, chicken and impala dents on the bodywork. From the radio, I caught the end of a programme: “… sadly, that’s the tragedy of the hedgehogs.” Apparently our spiny chums, seemingly incapable of internalising the essentials of road safety, are dwindling in numbers. This, it transpires, (unless you are an ant, or part of the pro-ant lobby), is bad news. I could not help dwelling on our separate understanding of the idea of tragedy. Funnily enough, as we cruised along the familiar A45, (Oh! the glorious A45!), I could not extinguish my relief to be home, even with thoughts of the tragedies I had seen. It needed a prickly comparison to bring home to me the privilege of my circumstances. Soon I would be eating a Taylor’s Welsh Dragon sausage. I would be drinking a glass of Malbec, in our comfortable home, in our comfortable neighbourhood, surrounded by my healthy family and friends, in our peaceful country. (Albeit made more peaceful by lack of hedgehog revelry.) What a blessing.

I arrived back in Earlsdon, the door was flung open, and I was hugged into the house. Five minutes later, I was pouring real, liquid milk into a cup of tea. (I knew it hadn’t just been an imagined memory.) Then, joy!, Freddie, my one-year old grandson, toddled in and eyed me intently, brow deeply furrowed, for a full four minutes. This was a moment I had feared: would he remember me? We had been so close before. Now, however, not only had I lost a lot of weight, but also I had adorned the physiognomy with a smart, closely-trimmed, attractive, designer beard. (“You haven’t bothered to shave” seems to me a much harsher way of expressing it, especially when shaving in Africa was a waste of two precious minutes of sleep before the 7.30 start.) When looked at from the right angle, my resemblance to George Clooney, or Sean Connery’s much younger brother was now uncanny. After four soul-searching minutes, Freddie’s brow unfurled, a big smile unfolded, and the arms lifted towards me for a long, long, where-have-you-been cuddle. Home!

Mis came back from work that evening and we met outside on the path. This year, we have been together for forty years, and in all that time, this was the longest we had been apart. Our eyes met, and maybe I’m reading too much into that deep and unspoken gaze, but it seemed to say, “At last! Someone to mend the bathroom tiles!” I jest of course, and, for the soppier readers of the blog, I have to admit to a slight moisture in the eyeballs, at seeing my lovely wife again. After just two months! How mad is that.

“So what was it like?” someone asked. How could I sum it up in a word? I decided on: “Big.” That seemed to do the trick, and as no-one asked for further amplification, willing messengers were then dispatched, one to the frying pan and another to the wine rack.

The next morning, sausaged and malbecked to the gunnels, I had time to reflect on what next. There is a long road ahead, but staying where we are is just not an option, even if it were wanted. The world is striding ahead apace. Whilst I was in Berega, electricity arrived. I was there for the first caesareans done without the background hum of the generator. Roads were being built. Concordats were being signed. There were even plans for water to be piped from the lakes to the dry, high centre. One of the most bizarre developments was even ahead of the UK: last month Berega began to pay all their staff salaries using mobile-phone money: credit that you can then text to any other mobile phone. In June 2013, staff took the three-hour bus ride each way, and the two-hour bank queue, to pick up their monthly salary in hard cash. In July 2013, they could buy a kilogram of rice in the mud-hut village store by mobile phone credit transfer.

Progress is happening. Change is coming, and we have to be moving. Once the anchor is up, and the sail is set, the wind might blow us where we need to be. Mothers and their babies must not be left behind.

I annexe the first draft of The Plan. Let’s just begin, and see where that leads. I am in for the long haul, all being well, and I commit to being a stimulus, a catalyst. At the Tanzanian end, we have utmost commitment from the hospital bosses, and determination in the direction of travel – as evidenced by the new charter of standards in the hospital. We have a number of volunteers lining up for future medical involvement with the hospital. Most of all, however, we have a daily tragedy unfolding, which, with a little effort and some limited resources, we can begin to tackle.

I need money. Not huge amounts, but about £20k/year for five years. With that, we can transform our chosen isolated village of Mnafu from being a distant and inaccessible place where women and children needlessly die, to one where they have a realistic chance of a healthy future. The accompanying draft plan gives you the flavour of what we will be doing.

Can you help financially? If I had forty people each giving £500, that would pay for the first year, and then it is up to me to stimulate the developments that might entice future investment. Or you might just have £50 to spare, or £5, and that would help. But let me tell you very clearly: Not a single penny will be spent on administration, on overheads, or on any form of greasing the wheels. I will be writing the blog fortnightly for as long as I am getting support, and I will be demanding hard evidence of progress. Progress might be as simple as liaison, talking, engagement with the community, and all the preludes that will lead to the twenty-first century. But we have a plan, and the worst that can happen is that it fails.

If you do not want to give money, don’t worry – I know that many people are already over-committed, and if you are struggling to get to the end of the month, it is not you I am targeting. Even if you are rich, but this is not your thing, that’s fine, and please still be my friend.

But if you have been looking for someone and somewhere to send that extra few quid that Aunty Edna left you that you did not really need, then I am that someone, and rural Tanzania is that somewhere. Email me on email.lozza@gmail.com, and I will give you details of how to make Gift Aid payments. Alternatively, just ask for the account details, and put in what you think is right.

I am not saying to ignore the hedgehogs. By all means encourage the repopulation of our hedgerows with these diminishing denizens of the darkness. But the much more urgent tragedy that is happening out there also needs our attention. We cannot make the whole world right, but why not try to make just one bit of it better. 

One day, an Mnafu mother will be smiling down on her new baby, wondering why those wazungu so far away cared so much.

Laurence Wood

email.lozza@gmail.com

At last back in the world of fast internet, I can give you some moving pictures! The road to Mnafu shows the beginning of the road from the hospital. Mnafu is about an hour further on.

Road to Mnafu:  http://youtu.be/cDGP2GJRWuA

http://www.youtube.com/watch?v=cDGP2GJRWuA&feature=youtu.be

Hospital House: http://youtu.be/n84o3Mztf9o

http://www.youtube.com/watch?v=n84o3Mztf9o&feature=youtu.be

Berega Hospital: http://youtu.be/D9YBOYn10FA

http://www.youtube.com/watch?v=D9YBOYn10FA&feature=youtu.be

Sion Bird: 

http://www.youtube.com/watch?v=M0MYNAN98aI&feature=youtu.be

For reference: Technical notes on obstructed labour and assisted delivery in rural Tanzania

Obstructed Labour and Assisted Delivery in rural Tanzania

Notes for professionals – and the technically-informed curious.

The puzzle of obstructed labour in rural Tanzania

The strange facts needing to be reconciled are:

1.      1. Most of the emergency CS’s in the UK are due either to a CTG diagnosis of fetal distress, or to a long, slow, seemingly dysfunctional labour; or both. Long slow labours are typically the product of induction of labour, or are primips in labour where the diagnosis of active labour was made too early. Fetal distress mainly comes from CTGs.

Where we have no induction, nor CTG, nor anxious primips coming in too early, the CS rate in Berega should therefore be much lower than the UK. However, it seems, if anything, to be higher – more than 30% of deliveries. This is presumably because we are skimming off the caesareans from a much larger population than just those who give birth at Berega.

2.       2. Obstructed labour is far and away the most common indication for CS. A few CS are done for eclampsia, twins, breech, post-dates with very high head, etc. However, far and away the most frequent indication for CS (90% in my two months here) was obstructed labour.

This is wildly different from the UK, where although the CS rate is more than 25% of pregnancies, only very few of these – 1 or 2% of deliveries if that – have full-blown obstructed labour.

3.       3. You may conjecture that this might be due in part to over-diagnosis of obstruction. However, when women get obstructed labour in Berega, the diagnosis is typically barn-door. The head is very high abdominally: often 3-4/5 palpable despite eg 14 hours or more of active labour – even in multips with several previous normal deliveries of seemingly similar-sized babies. In the UK, obstruction can be difficult to diagnose, as the head is often well down, and the diagnosis is less obvious.

4.       4. In obstructed labour in Tanzania, caput seems to be an important sign. They also have the classical signs, (see below). However, the heads seem to get more severe caput than they do in the UK – perhaps just a feature of longer labours not dealt with earlier? Or something to do with the traditional medicines taken?

5.       5. When reviewing antenatal women, the head just about never engages. It is either free or 5/5 palpable right up to labour.

6.       6. Obstruction is almost always in the first stage. In two months here, I have seen around 70 CS, but only three second stage obstructed labours. Two were an easy Kiwi rotations, in the presence of a tired mother, and an OT or oblique OP position, where there was minimal caput and moulding, and decent descent of the head with contraction. The other was the opposite – lots of caput, (difficult to determine position), and stuck right at the outlet. In this one, a Kiwi pull failed, and CS was needed. The baby was born in poor shape with a very sausage-shaped head.

7.       7. I did one other successful Kiwi – for eclampsia, a delightfully easy delivery, making the Kiwi rate around 2% in my time at Berega. (3 of them successful, one not.) I did no forceps, nor (surprisingly), did I see an indication.

Again, this is in sharp contrast with the UK, where the combined vacuum + forceps rate is often 15% or more of deliveries. If we are indeed dealing with the problems arising from a much bigger population, then we should have a higher instrumental delivery rate than the UK, not a lower one.

It is true that many instrumental deliveries are done for CTG problems in the UK, but many also are done for failure to deliver, often associated with malposition. Even when the baby is OA, the need for forceps to deliver because of a tight fit is common. Here I did not see it once.

8.       8. In Berega, fetal distress is rarely an indication for CS or assisted delivery – probably related to the lack of CTGs. FH auscultation is done badly. Nevertheless, for all that, when the baby was actually born vaginally, it was rare during my two-month stay, (possibly once or twice a month), for it to need resuscitation.

However, I did run an intensive update on resus, and I have no idea what the death rate from vaginal delivery was before I came.

9.       9. According to the Berega records, the death rate of babies in obstructed labour was horrifically high before I arrived. The combined perinatal mortality rate over the 7 months 1^st Dec 2012 to 30^th June 2013 was 9% of deliveries. In the UK, it is below 1%.

Some of this was poor resuscitation of babies born in poor condition, often after a GA caesarean*. (Despite annual resuscitation updates from a highly skilled paediatrician, the skills obviously waned without constant reinforcement – a salutary lesson.)

In other cases, a few babies died, even when I was there, from being un-resuscitatable after CS for obstructed labour. This presumably relates either to late presentation, or, more commonly, to failure to pick up profound fetal distress early enough.

10.   10. The huge majority of women with obstructed labour admit having taken local medicines.

11.   11. This all represents a hugely different pattern of obstruction in Tanzania from my previous observation of Zulu labour – also a Bantu race. (I worked in a rural hospital in KwaZulu-Natal for four years.) There, outlet obstruction is far more common, and first-stage obstruction is rare. Vacuum delivery was a common need – sometimes with symphysiotomy, (which was preferable to what would otherwise have been a dreadfully difficult CS, with the head crowning but undeliverable vaginally).

Zulu women in general have much more of a sticking-out bottom – rural Tanzanian women are often flat by comparison. (They are also thinner and less female-shaped than their urban sisters.) Zulus are also considerably taller, and often stocky. Rural Tanzanian women are typically below 160cm, and are almost always slender – sometimes markedly so.

Reflection

The differences in body-type between KwaZulu-Natal and rural Tanzania may be due racial differences – eg Tanzania includes Nilotic tribes who are traditionally slimmer. However, Zulus are Bantu, and their antecedents originated in East Africa just a few centuries ago. It may therefore be that malnutrition in puberty in Tanzanian girls causes failure of development of the full gynaecoid pelvis, perhaps related to insufficient oestrogen.

A second conjecture relating to the markedly different pattern of obstruction on Tanzania, is the common consumption of labour-enhancing local drugs. 

Clearly, when a primip not in labour is given such a drug, it may readily cause distress before it causes delivery. Similarly, in a multip given such a drug inappropriately in early labour, she may end with rupture.

However, I wonder whether these drugs also interfere with the natural mechanism of labour? We have already established that as many as 90% of women referred in from the community have already taken these substances. Some of these women should not have developed obstruction – eg previous quick normal deliveries of a similar-sized baby. Do these local medicines somehow cause a type of contraction which has all the harm of squeezing the baby and exhausting or rupturing the uterus, but without the enhancement of natural labour? Is the cervix or pelvis or pelvic floor somehow not ready?

Finally, we know that for every delivery we do in the hospital, at least ten occur in the community. Perhaps our obstructed labour workload comes from the arrival at hospital of those women from the villages who get stuck. Most other causes of problems in childbirth – eg fetal distress, breech – would not cause a woman to travel a long way on bad roads on a motor-bike. Obstructed labour, however, means that she will not otherwise deliver in the village, and so the only other option is to die.

An interesting mathematical conclusion thus arises: We could examine our CS indication rate over a long period, and then compare the rates of ‘eclampsia’ and ‘obstructed labour’. We could then compare this ratio to that in a major city. 

Assuming that most village-based eclampsias do not arrive at hospital, (a long way to bring a fitting lady on a motor-bike), but that most obstructed labours do, the comparison of the two rates may allow us to infer how many extra obstructed labour cases we are doing, by comparison with eclampsia.

It would thereby give us an rough idea of how many women are delivering in villages in our territory, from which we could calculate how many common problems must be occurring there – eg breech, twins, eclampsia, fetal distress, etc.

Suggestions for the management of labour in Tanzania

1.       1. The diagnosis of labour is critical. The partograph is meaningless if the woman begins it many hours too early, or many hours too late. Therefore staff should not only be taught but also tested and checked within in-service training, (IST), on the diagnosis of labour.

2.       2. Using cm of dilatation to diagnose labour can produce considerable inter-observer variation. Nevertheless, the midwife needs to be clear that the os is not just a multip’s os, but is in fact at least 3-4cm dilated. More important however, than trying to tell the difference between 2cm dilated and 3cm, the midwife needs to be absolutely clear that the cervix is fully effaced; and that contractions are coming regularly, at least every 5 minutes. They need physically to feel the entirety of the contraction with their hand.

At full-term, a working definition of active labour is the combination of:

·  

- cervix open at least two fingers; plus

- cervix fully effaced and thin; plus

- regular spontaneous contractions each lasting 40 secs or more, coming every 5 minutes or more 

3.  Once labour is diagnosed, the woman should be entered on a partograph. Use of the partograph also needs IST. Ideally, a woman should not be left alone once active labour is diagnosed. However, that is impractical, so a bare minimum of observations need to be insisted upon, to ensure that the woman at least is seen and checked every half an hour in the first stage. (And every 5 minutes in the second). 

Most importantly, at these times, the FH needs to be auscultated – after a contraction. This again needs both in-service and classroom-based updates.

The normal observations of pulse, BP, and contractions can be recorded at appropriate intervals, depending on clinical circumstances.

4. In addition to in-service training, midwifes need regular in-service checks to ensure that they are able to tell the difference between a normal FH, and an abnormal one.

5. Whenever a labour is abnormal, the doctor needs not only to be informed, but to come and check the woman.

6. If second stage has not occurred by the transfer line, the woman should be transferred.

7. If no second stage has occurred by the action line, but the FH is still good, then the whole situation needs assessment. However, pay particular attention to the station of the head. If it is still 2/5 palpable or more in rural Tanzania, then obstructed labour is extremely likely. If the labour has been long, with good contractions, but the head is still high in the abdomen, then a vaginal examination should be done, but will probably just confirm the diagnosis of obstruction, and a CS should be ordered. (Rather than augmentation and/or giving time for the obstruction to become impacted.)

8. Membranes should only be artificially ruptured when not to do so would probably deny the woman the chance of a normal delivery. The typical situation in which ARM would be appropriate would be a slow labour in a multip, where contractions could be better; where the FH is good; where the head is not high abdominally; where the presentation is definitely uncomplicated cephalic; where the position is probably OA: and where plenty of time has already been given for SRM, so the next step would otherwise be to call the doctor.

Even then, ARM should not be performed in someone about to be transferred, as labour will get stronger. Hypoxia of the baby secondary to obstruction does not occur if the membranes are intact. Intact membranes also protect against cord prolapse, when the presenting part is ill-fitting.

Suggestions for the diagnosis of obstructed labour in Tanzania

When the doctor is called, s/he has to decide whether the labour is obstructed. A suggested guide is:

1. In rural Tanzania, it seems that the head stays high in the abdomen in obstructed labour. The combination of a long labour, (where diagnosis of labour had been good); plus good contractions actually palpated; plus high head abdominally, is very likely to mean obstruction.

2. As mentioned above, caput seems commoner and more severe in obstructed labour in Tanzania.

3. Additionally, the accompanying factors are typically: on vaginal examination there is an empty pelvic curvature at the back of the V/E, even though at the front of the vagina the head is easily palpable; no descent with a good contraction; moulding should be present, (if sutures can be felt); poorly applied swollen cervix; and eventually vulval oedema and haematuria.

4. Once the labour is actually obstructed, the baby will increasingly get hypoxic, and previously clear liquor will become increasingly meconium-stained.

Suggestions for the use of Kiwi Omnicup and Forceps in Tanzania

The Kiwi Omnicup has an important place in Africa, where it may not only prevent caesarean section, (and therefore problems in future pregnancy), but may save life. However, it use should be considerably more limited than is normal in the UK. My suggested rules are:

1.       Certain rules should be as for the UK: Fully dilated; Head not palpable per abdomen; head comes down with contraction; placement of the Kiwi on the flexion point; no other contra-indication to Kiwi such as HIV; etc.

2.       Kiwi Omnicup should never be used for (relatively) obstructed labour in OA position, I believe. A technical reason for saying this is that in OA position, the tendency of the omnicup is to increase deflexion, whereas in OP position, it corrects deflexion.

However, more important than this is the balance between risk of good and risk of harm. To do an omnicup delivery for slow progress in OA position (ie when trying to overcome a tight fit), would be to suggest that even though the head is correctly placed, by traction on just a small area of the baby’s scalp, you would hope to succeed in the large majority of cases, and only rarely get unfavourable consequences for the baby. That does not usually make sense to me.

I think that too often, the rural Tanzanian pelvis would be fooling you into thinking that vaginal delivery was possible, whereas in fact, the mother had only just made it to full dilatation. You would therefore fail too often, and the baby in these circumstances might have suffered from the intervention – eg cephalhaematoma, or even cerebral haemorrhage. Additionally, a failed Kiwi in such cases would make the CS more difficult, and therefore the baby would be more hypoxic.

3. The Kiwi omnicup comes into its own for correction of malposition – OP or OT, with or without asynclitism and/or deflexion. In prolonged second stage – or earlier if the baby is distressed – the Kiwi will very often turn the baby readily on the first pull.

Thereafter it will come quickly, as long as the pull is correct, the pushing is maintained, and the contractions are satisfactory. Such Kiwis will save unnecessary CS. Despite a small risk of cerebral bleed, they will often help prevent severe hypoxia in the baby, and the balance is therefore very much in their favour.

This is particularly the case, as there are some mothers where delivery should be easy, but malposition prevents it from being so – eg twins, grand multips. Nevertheless, such indications probably do not amount to much more than 1% of deliveries.

4. Remember that the first pull especially must pull the head into the levator ani, and into the woman’s perineal body. If the baby's head is pulled into the woman’s pubis bone, clearly it cannot advance. The perineal body, by contrast, is soft, and the levator ani naturally assist in the turning of the head. PULLING THE HEAD TOWARDS YOUR CHEST, YOU MEET HARD PUBIS. PULLING THE HEAD TOWARDS YOUR GROIN, YOU MEET SOFT MUSCLE. SO PULL DOWNWARDS!

The Kiwi should not be pulled above the horizontal until the head is half-born!! (It’s just physics – with less than half delivery of the head, if you pull above the horizontal, the fulcrum is passing through the pubic bone.)

5.The other important place for the Kiwi is when a quick delivery is required in the absence of prolonged labour – eg eclampsia; fetal distress; second twin; abruption. Such indications currently probably do not add to more than 2-3% of deliveries in rural Tanzania, but with better fetal monitoring, the diagnosis of fetal distress would increase. (And with CTGs, it would increase too much!).

In such situations, especially in multips, a Kiwi can be quick and simple, and will often save at least the brain, if not the life, of the baby. A CS for mother can also be avoided – eg distressed second twin with high head, eclampsia with poor maternal effort; etc.

In such a real crisis in a multip, you may get a good Kiwi delivery even at 8cm. In a grandmultip, she just needs to be in good labour, and you can push the cervix away!

6. I suggest that non-rotational forceps currently have little place, though this may change. They need the head to be OA, and they need good analgesia and a decent episiotomy. In the UK, one cautious and judicious pull with (eg) Neville-Barnes forceps can make the baby deliverable where this was uncertain. By contrast, it can confirm the diagnosis that the baby is stuck and CS is needed. In this case, the forceps can be used to disengage the head before they are taken off.

However, stuck OA head in second stage seems very rare in Berega – I have not seen one. Furthermore, where it does occur, I conjecture that it would be common for the head to be truly stuck and vaginal delivery impossible.

The place for Neville-Barnes forceps is thus very limited – for a woman who needs vaginal delivery to be expedited; where the head is OA; she is fully dilated with no head palpable abdominally and no other signs of obstruction, (in particular, be wary of caput); she has sufficiently good analgesia or does not need it; and the operator is skilled with the instrument.

Effectively, this amounts to certain clearly-defined situations: fetal distress not caused by obstruction; eclampsia; after-coming head of breech; abruption; poor maternal effort; the need to protect the mother – eg in heart disease; needing to avoid a Kiwi – eg HIV; etc.

In such circumstances, the availability of skilled forceps delivery is vital, so forceps still have an important place.

It is likely that as obstetrics improves in rural Tanzania, these indications will become more common.

*Post script

In Berega, GA CS is far too common. The typical reasons were either because of having run out of spinal lignocaine, or because of a cautious anaesthetist not wanting to give a spinal to a mum with a low Hb, in whom the ward staff had omitted to give an IV fluid bolus on the way to theatre.

The GA is done with a variety of induction agents, often added together ad hoc until she is asleep, then halothane plus mask. There are no facilities for intubation, and no antacids are given. Post op, patients are left alone, on their back, often deeply asleep for many hours, untended, with an airway in. 

When visitors ask what they can bring, one idea is battery-driven pulse oximeters and BP monitors, and then put them right in the hands of an anaesthetist you trust. Insist on their use when you do a CS. And regularly without embarrassment ask "What are her vitals?"