30. In the Dog-house

For consumers of the annals of human endeavour, two memorable morsels ricocheted around the social media last weekend. The one you are less likely to have sampled is the sight of Queen Elsa pouring an ice-bucket over the head of a well-meaning but gullible ex-obstetrician:

https://www.youtube.com/watch?v=FBvbg3yeslo

The intention was to raise funds to stop mothers dying in childbirth; to give hope to communities in rural Tanzania; to help a part of the world where each village has ten children die every year:

http://yellowchuckchucks.blogspot.co.uk/2014/09/what-size-for-womens-groups-in-rural.html

http://yellowchuckchucks.blogspot.co.uk/2014/08/embrace-tushikmanane-where-we-are.html

It’s only a week on, and maybe these things trickle through slowly, (or maybe Threadneedle Street is scrutinising the destiny of such an exodus of bullion), but nothing much seems to be happening on the fundraising site:

https://mydonate.bt.com/fundraisers/embrace

(I suppose another possibility is that the Bank of England was waiting until Scotland Has Decided. It would be awful if they paid-the-bearer-on-demand-the-sum-of lots of Sterling, only to discover that the donor had been Scottish. A dreary process would then ensue, of trying to get the bullion back in return for the Scottish GrOats.)

The story more likely to have captured your attention was the burning down of the dog’s home in Manchester. The home is a sort of refuge for dogs, where they can find friendship; comfort; posts smelling of other dogs’ urine; and, if needed, counselling. It is a sign of a deeply sophisticated society that we care in this way for a species that has brought to ours so much in the way of comfort, unquestioning friendship, and chewed sticks. I have noticed in my short transit through Life on Earth, that a person who is kind to humans is rarely cruel to animals.

Looking after dogs, then, is a noble enough undertaking, and it would not have been surprising to have observed generous support after the home was tragically struck by such a devastating fire. What was more than surprising – even astonishing – indeed ‘Blairs-decide-to-retire-to-holiday-home-in-Merthyr-Tydfil’ level of unlikeliness – was that in just a single weekend, they raised £1.2 million for the re-building of the dogs’ home:

http://www.bbc.co.uk/news/uk-29204953

I know that my ice-bucket challenge did not tap into the same market, and I do not have the same appeal: Apart from the lower half of my face I am not furry. I do not have wistful eyes.

If someone throws a tennis ball, I am perfectly capable of almost completely ignoring it. I am not intrigued by the smell of other people’s trousers. If I find anything disgusting whilst walking through the park, I am neither tempted to eat it nor roll in it. I am allowed on the sofa.

I could go on, but I am conceding the point that I lack the canine X-factor. In a head-to-head fund-raiser between Lassie and I, to buy somewhere to rest our weary heads, the collie-dog would have the donors rounded up before I had even downloaded the Lottery’s “Fifteen Things You Should Know Before Applying For An Ageing Hippy Weary Cranium Residence-Enhancement Grant”.

But what would Lassie think about spending that amount on her home, at the cost of her owner’s life, and those of her children? If dogs really are a person’s best friend, would they truly want to move into million-pound kennels when, 5000 miles away, the young lads who would love to scamper with them are beset by malaria, malnutrition, infestations, infections, and tragedy; and who, too often, will never throw a stick again.

I do not exempt myself from this sobering reflection. What I have spent on our two dogs this last dozen years would have paid for many wells. For a school perhaps. For a land-rover ambulance. For many, many emergency C-sections, performed in poor light on mothers desperate to survive and see their child.

Where would we be, though, if suddenly we were equitable in the distribution of our largesse? Theme parks and cinemas would close down as pleasure-seekers found new comfort in sending their spare cash to the needy. The clothing industry would grind to a halt as we wore what we wore until it fell off our backs, giving the money released to the naked and the cold. Malbec producers would call an emergency summit in Mendoza, as I replaced my nightly nectar with enough dirty water to moisten my mouth.

The world is not fair, and never will be. For there to be wealth-sharing, there has to be wealth.

But, on the other hand, where would we be, in this tragically unequal world, if we closed our ears to the anguish of death and tragedy, albeit in distant lands? Where would we be if the cries of the suffering and the desperate never penetrated our cocoon? Where would Lassie be, if, knowing that all this was going on in the world, she accepted a millionaire’s kennel?

For me, dog-lover though I am, I know where I would be if I ignored humanity in favour of other species.

In the dog house.

Guest blog: Dr Olivia VandeCasteele

Role: A visiting doctor from Belgium

Last year, on the 20th of november, my partner Cédric and I arrived in Berega, to stay there for two months. 

https://www.youtube.com/watch?v=D9YBOYn10FA&list=UUcGPVMRnWyglSeIJ4sssvQg

Before I came to Berega,  I had just graduated as a General Practitioner and finished a degree in Tropical Medicine. Dr Sion Williams, who had been working here for a year, invited me to come and help in the hospital. 

In the beginning I was working together with Sion on the ward, particularly with women and children. After 2 weeks of adaptation I started working in the out-patient department where the 'clinical officers' examine and treat walk-in patients and decide who will be admitted in the hospital. 

These clinical officers are recruited either from nurse graduates or sometimes directly from secondary education – though often they will first have had to work for some year to find the money for their training. They spend 3 years in Clinical Officer training, which is mostly practical. I tried to learn how they work and tried to teach where appropriate (optimization of their clinical examination, broadening of their knowledge of differential diagnosis and antibiotics,…)

Although there were times when Sion and Abdallah had been the only medical staff here, during my stay we were working in the hospital with 3 European doctors, 2 Tanzanian doctors and 5 clinical officers! All the doctors and nurses are given a house on the compound . We were living with ‘the Europeans’ in a big house, with a huge kitchen and living room and several sleeping rooms:

In the evening we could go for a beer in the ‘pub’ – a small  hut in the village with an awning and chairs outside, that last year at last acquired electricity and a fridge!

Check out:

http://youtu.be/7XLrmd-qAGg

We bought our food in the little stalls in the village:

or at the weekly Monday market:

At weekends we rested, visited Morogoro and explored the surroundings of Berega. 

https://www.youtube.com/watch?v=cDGP2GJRWuA&list=UUcGPVMRnWyglSeIJ4sssvQg

We were invited to a Christmas party at the orphanage, with a great meal and a lovely performance of African singing and dancing. (The hospital has its own orphanage ...) On the evening before Christmas we cooked our own meal and celebrated together at home.  On Christmas we were invited to join celebrations in the village.

Cédric, my partner, signed up to do some community work. He works as a chef, and taught children at the local school how to bake during their summer break. He gave driving lessons to local women in the village. He also worked with a charity in the village called ‘Hands for Africa’by trying to make soap from local products, produced on the farm, and by visiting families in the village in order to give the children a chance to get a scholarship at the local English language school.

It was difficult to leave Berega. Sometimes I feel guilty that I only stayed for 2 months, that I didn’t do more for the village. You could work here forever, because it feels like they will always need doctors. And you need to get to know them. 

If you read this and you are planning to go there, I truly advise you to do so!!

29. Whatever ...

When I was a practising obstetrician, helping women to prepare for childbirth was an important part of the job. This especially applies to the birth of the first child, which Natural Selection, in a harsh and impassive demonstration of its single-mindedness, has made by far the toughest.

Being a left-leaning, feminist, empathic sort of person, with only mild Asperger’s syndrome, I might easily have been tempted to recommend that women in labour listen to whale music in a giant tub of yoghurt under an oak tree with their partners messily massaging the small of their back until second stage kicks in. 

Had it not been for our first childbirth.

Jenny took five days to decide to come out above rather than below the bladder. The emergency C-section under general anaesthetic has been a familiar shipwreck of the dreams of far too many couples.

At first, I used to believe that this meant the need for more intense childbirth preparations, particularly in relation to managing one’s expectations. Then a weird thing happened. I noticed that those least likely to make such preparations – teenagers from less privileged backgrounds – often had remarkably good labours. When asked in advance what their birth plan was, such a person might typically say, “Whatever …”

Eventually, I stumbled on the obvious answer: It is all about dealing with stress and anxiety. More stress: more adrenaline. More adrenaline: more pain; tighter pelvis; weaker contractions.

More chilled: more natural oxytocin; more compliant pelvis; stronger contractions. More 'whatever'. Childbirth preparation helps, but it does so especially in proportion to the amount it helps you take control, at the same time as relaxing and let it happen. 
(Easy for a man to say.)

(For a man to write, actually. Asperger’s kicking in.)

So I ended up spending a lot of time explaining to first-time mums the need to chill out at home as long as possible, (as long as all was well and the baby was moving normally). Have a bath. Have something to eat. Go for a walk. Watch an East-Enders box set. OK, perhaps not East Enders. Anyway, chill. Have the transport ready then only get in it when you reach the “Get this baby out!” stage.

It shows what an English city-dweller I am, than in all these considerations, it never struck me to doubt that the transport would always be there. Not just the car, but someone to drive it, fuel to put in it, money to pay for it, and a short road to drive it along.

This set of thoughts has been flashing through my head because of a recent email from Berega: A bus and car crash near the hospital has led to 49 admissions, many of them critical, in a hospital whose resources are already badly overstretched.

In Tanzania, there are no tarred roads in rural areas. Just dirt roads which get flooded and scarred by the ironic flashes of angry waters through this parched landscape.

In 2010, there were 1.24 million deaths on the world’s roads, most of them occurring in countries like Tanzania, where overcrowded transport, packed with the poor, the needy and the pregnant, recklessly charges towards its destination; or sometimes its destiny.

In the territory of Berega Hospital, the problem is made worse by the unaffordability of cars. Bikes and motor bikes are the only ways to make a longer journey. And they are by no means always satisfactory.

                                       

 

    

My mind goes back to two of the most disturbing memories of my time at Berega – both of them relating to transport rather than health. One was of the woman who came from a distant village on a motorbike having been in labour for five days. For the last three days, the baby’s head had been out, and the body still in. In that state she managed the unimaginable middle passenger journey to reach help. More unimaginable still was the woman who arrived too late, having bled just too much on the bumpy ride in. Her body was taken back to her village and her family, a lifeless middle passenger on a bumpy ride back.

When I went to Tanzania, I had imagined that health services were the central plank in the strategy for saving mothers’ lives. But just as the causes of death are complex, so are the solutions. Fabulous maternity services that no-one can reach, that no-one can afford, will save no-one's lives. Whatever we do, it has to involve community development. It has to address, more urgently perhaps than any health priority, those issues which prevent access to care: for instance poverty, lack of female education, and poor transport.

Whatever solutions exist must, (the WHO now tells us), be first articulated by the village women themselves, if they are to be pursued sustainably:

http://apps.who.int/iris/bitstream/10665/127939/1/9789241507271_eng.pdf?ua=1

Whatever we do, we must get out into communities and engage with pregnant women and their sisters and their carers, if we do not want them to become next year’s mortality statistics. Whatever these mums feel might be the solutions, be it to poverty or education or transport, those are the directions in which we must travel.

Whatever.

For reference: What size for Women's Groups in Rural Tanzania?

EMBRACE-Tushikamane 

'Empowering Mothers & Babies to Receive Adequate Care & Equality' - 

'We are joined in solidarity'

This is a technical note for those who might be planning on setting up women's groups in rural Tanzania, with a view to trying to reduce the dreadful maternal and neonatal mortality rates.

One of the early planning questions is exactly what size of territory a women's group should represent; what that means for the number of 'Community Facilitators', (CF); and the implications for the demographics within that small population.

Here then is some useful info based on published data, for those doing any such planning:

Tanzania has an official village and hamlet structure. 

A 'hamlet' is 100 households. A 'village' is 3-4 hamlets. (See http://en.wikipedia.org/wiki/Poverty_in_Tanzania)

This is what a hamlet looks like in rural Morogoro region: http://www.youtube.com/watch?v=cDGP2GJRWuA. 

If one women's group should could cover (say) 700 population, then in rural Tanzania this would mean:

• one hamlet per women's group may be just about perfect: it contains around 700 people, (if 7 people per household);
• this covers about 6 x 4km of territory, (pop density 31/sq km); 
• each hamlet of 700 people might have 28 births/year, (Crude birth rate 39); 
• (of which mothers at least a third should be in the group); 
• there may be 175 women of reproductive age, (WRA 47%); 
• the healthy of whom would go on to have more than six children, (fertility rate 6.3)
• With a MMR of 454 in Tanzania as a whole, and ??750 in rural areas, there would be one maternal death every 5 years for each hamlet /women's group;
• Infant MR of 51, and under-5 MR of 81 in the country as a whole, are serious under-estimates in rural areas, so of the 28 births, perhaps 2 neonates and one further under-5 will die each year per hamlet.  (see: http://www.nbs.go.tz/nbs/takwimu/references/Tanzania_in_figures2012.pdf)

With one Community Facilitator of Women's Groups covering two villages, ( = 8 hamlets & 8 Women's Groups), this would be a population of around 5,000. 

That would mean that each CF would start off with one maternal death and 20+ baby/child deaths per year on her patch - huge scope for any intervention to show benefit.

Guest blog - Laura & Sarah: UK doc & nurse working at Berega for a spell

First impressions of working at Berega

Our names are Laura Pearson and Sarah Leftley, a young doctor and a young nurse from the UK, and we have come to work in Berega Hospital for a spell, to experience first-hand the needs and challenges of rural Tanzania. 

http://www.youtube.com/watch?v=D9YBOYn10FA

https://twitter.com/BeregaHospital            @BeregaHospital

http://beregahospital.org/

We are staying in the guest house that the hospital kindly (and wisely) makes available to any visitor:

http://www.youtube.com/watch?v=n84o3Mztf9o

Laurence asked us to sketch out our first impressions, coming from the sophisticated NHS, to a mission hospital in rural Africa.

Here are our first thoughts.

Doctors & Clinical Medicine

Doctors are expected to be specialists in everything - this we can't get our head around this - the doctors here are physicians, surgeons, GPs, paediatricians, obstetricians and so on.  Their jobs are extremely hard - often on-call 24 hours a day for a number of days.  Often there is only 1 doctor to see in excess of 50 inpatients and then to undertake any operations that are needed.  We can't imagine what a consultant surgeon would say if he was told he had to do a ward round on the paediatric and geriatrics wards!

Ward rounds are 3 times per week, but often incomplete, some patients not getting seen for 5 days or more by a doctor - this is due to time constraints and demands on the doctors.  However, sometimes sick patients are not flagged up by the nursing staff, which is a worry as deterioration is missed.  However, even though these patients are paying for their hospital stay and for their treatments, we haven't heard one person complain about any aspect of their care.  At home, people complain they've waited a hour to be seen in a walk in clinic and relatives will complain if they haven't been able to speak to a doctor for 1 day!

Lack of access to investigations and medications makes management challenging.

Death

The resignation of people to neonatal death shocked us.  We can only suppose that is seen so often here that people seem to almost expect it and accept it as the ordinary.

A 31 year old lady planned for c-sec went into labour before c-section date.  She was found to be anaemic.  No blood in the hospital.  The family had to donate blood before she could  be taken to theatre.  Once in theatre (delayed by 5 hours or more) she was found to have ruptured uterus and the baby died.  If blood was available and she had gone to theatre sooner, maybe the outcome would have been more favourable.  It's hard when you see this happen, knowing that it wouldn't happen at home. We just take that for granted.

It is important to note, that the staff here are working in very difficult conditions and most patients are discharged home after successful treatment.  Maybe at home we rely too much on investigations and machines when actually, nothing is more important than taking a good history and performing a thorough examination.   In our short time here so far, we have been reminded of this and we are learning from their ability to provide accurate assessments without any other tools.   

Treatments

There are more medications available than we had expected there to be. Cheap drugs from India mean that most conditions can be treated, if the prescription can be afforded. Everyone seems to go away with a prescription.  There's a book that all attendees are written in, along with diagnosis and treatment - we couldn't find a blank treatment box!  We were surprised that there isn't more antibiotic resistance, especially as most of the prescriptions are for antibiotics.

Staff and systems

The nursing role is very different - they do bloods, cannulas, while family members seem to provide care, give meds etc.  There also seems to be a large knowledge to practice gap as they seem to learn and be very knowledgeable in conditions when asked.  However they can't always seem to relate this to patients clinically and see the importance of derangements in observations (often low blood pressures are recorded and no one is informed or they don't relate this to the patients condition).  Ward rounds are often interrupted by chatting and other non-urgent matters by other staff which is very different to home!

Almost all patients now have observation charts at the end of their beds but getting the nurses to complete them can be a bit of a challenge and they mostly only see the importance in temperatures and no other vital signs!  The nurses do however work in very difficult conditions with limited supplies, but they also rotate around wards so there doesn't seem to be a lot of ownership/pride in the wards themselves.

As a result, patients can end up being neglected: A burns patient who had been in for 4 days and only been given 1.5L fluid and not had obs due to extensive burns - when we first met him he was tachycardic and shaking.  He hadn't been given pain relief for 2 days and had no dressings as they don't have the correct dressings here.   Issue here was in part lack of doctor availability and handover of sick patients and perhaps lack of education in nursing staff about management of burns and recognising a sick patient.

A child with meningitis who was very sick with fevers over 40 degrees for  a number of days and wasn't getting regular or complete observations.  When the observations were done, and the doctor assessed the patient and saw him not to be improving, he was able to change management.

Facilities

The sterility in theatre is better than we were expecting but we were shocked to see that for anaesthetising patients they just use a guedel airway!

The lack of privacy on ward rounds surprised us, but patients don't seem to expect it, which almost surprised us more.  The next patient often comes into the clinic room before the previous one has left, examinations on ward done with a very small screen that doesn't cover everything.

Money & Poverty

It is hard prescribing medications knowing that the patient or their family is going to have to pay - added pressure to get the right diagnosis and optimal treatment.  If a patients' condition changes - it is hard to change the medication knowing that the family has paid for the medication that they are already taking.  It's tough seeing patients who can't afford basic medications - some patients leave before completing treatment or only take certain treatments that are prescribed because they can't afford it.  It makes us frustrated thinking of the patients that we see at home every day who take the NHS for granted and moan about how bad it is, they really need to come out here and see what it's like in a developing country.

There is a pressure to diagnose there and then - no "go home and see how it goes, then see your GP if it gets worse", like we often do when seeing patients in A&E or MAU at home.

Diseases

Different diseases are predominant compared to the UK - death from malaria, burns, meningitis, childbirth, and accidents are all so much commoner.

Amazing Tanzanians

The ability of the Tanzanian people to remain happy and positive despite some of the hardships they face is wonderful to see and puts things very much into perspective.  Everyone here has been so welcoming to us and willing to help us as well as learn from us.

The frustrations that are outlined above are only the first impressions of our time here.  As time goes on, we are finding more positive things to take away to improve our practice at home and learning that not everything that is different is necessarily for the worse and that less investigations and treatment doesn't always mean poor care.  The doctors and nurses here do the best with what they have and outcomes are, for the most part, better than you might expect.

Guest Blog Rachel Blackmore - Meeting TBAs in a Masai community

Report of TBA Training 5^th and 6^th August 2014 in Bulati

 Introduction

This training was planned by WTWT in response to a request from the Traditional Birth Attendants (TBAs) in Nainokanoka ward, Ngorongoro Conservation Area, Tanzania. In this area there is severe poverty and hardship exacerbated by restrictive Conservation Area practice leading to human rights abuses such as insufficient food due to the banning of practicing agriculture.

It was given by Dr. Shemaghembe (Medical Officer for Nainokanoka, Alailelai and Naiyobi wards) Nurse/Midwife Peeiyo (working in the Nainokanoka Health Centre) and myself, Rachel Blackmore (Midwife from the UK and director of WTWT), with introductions, conclusions and some translating by and Ponja Tayai and Embapa Runguna (Tanzanian co-ordinators and employees of WTWT). It was funded by WTWT UK.

The training was a two day programme, run twice during the week 5^th- 8^th August. It was initially planned for 70 TBA participants in two groups of 35. The 70 were made up from 5 TBAs from each of the 13 sub villages in Nainokanoka ward. One training was to be held in Bulati village primary school and the other in Nainokanoka village primary school. In the event extra TBAs came to both sessions, so we trained 109 in all. This report covers the training in Bulati, which was repeated on 7^th and 8^th August in Nainokanoka.

Day One 5^th August

We staff, with 12 women from Irkeepusi and Nainokanoka villages, travelled by landrover to Bulati to join another 43 TBAs from Bulati village, more than expected, but all were welcomed.

We were met and greeted by the Bulati TBAs with singing, dancing and prayers. All participants joined in with this during the walk to the classroom.

11:00 Tea and chapattis were served before the training began and we set up the equipment to show short films.

11:30 Embapa opened the training with a prayer, and then we all introduced ourselves.

I (Rachel) welcomed everyone and Embapa translated:

I said that I was really pleased that the TBAs had asked for training and that as a midwife was very happy to be sharing in this with them.

Firstly I invited them all to give themselves a clap for all the good care they give to women and babies and for requesting this training. This was received enthusiastically with all of us clapping.

Then I said how much I was looking forward to this training, to hearing about their experiences and ways of practicing. I explained that we wanted them to feel comfortable to share their experiences and ask questions, so that we could all learn from each other.

They would then work out together things they could do to improve the situation themselves for women and babies. They would be realistic things that they would be able to afford, or that could be funded.

We would look at aspects of how bodies work, the help of the films and models, to help understand why some things are helpful and others are not.

I suggested the following timetable with flexibility according to how discussions went

Timetable

Day one: General health and antenatal care

Day two: Care in labour, delivery and the postnatal period.

             A TBA participating

 Day One:

I asked them why they had asked for training. A woman answered that they knew the traditional ways of doing things but wanted to know the modern ways.

Antenatal care

I then asked them why they thought women had problems or died in childbirth. They answered that women didn't go to clinic and so had diseases that they didn't know about. I thought this was a good answer, and it gave the opportunity to talk about diseases and other things which cause problems which can be detected antenatally and treated, or where delivery needs to be in hospital, such as: anaemia, preeclampsia, infections, bleeding and malpresentations.

This was a good lead into two of the films I had brought (Medical Aid Films) ‘Focused Antenatal Care’ and ‘Warning Signs in Pregnancy’, set in Africa. The Nurse/Midwife translated them into Maa as they went along and I paused them when necessary.

      Film: Focussed antenatal care

The TBAs said they found the films helpful in explaining things that could cause problems and what to look out for. One asked why bleeding occurred antenatally. I used the doll pelvis and placenta to show visually the different positions that the placenta could be and how it was a big problem if it lay across the opening to the uterus. I also showed how sometimes bleeding could come from the edge of the placenta.

They were aware of the common problems which arise antenatally, for example headaches, bleeding, infections and anaemia. When women had headaches first they encourage the women to drink a lot and take traditional medicine. They admitted that it doesn’t work and that they then refer them. Now they will refer straight away. Dr. Shemaghembe advised them not to use traditional medicine during pregnancy and childbirth, but to refer for problems.

The film covered signs of infection such as fever and offensive vaginal discharge and stressed that it was very important to go for treatment in these cases. The pictures were very clear with diagrams of smelling discharge and women shaking, with a faster heart beat, sweating and looking hot. The TBAs said they do refer women to the medical centre for this.

We spoke about too much fluid, polyhydramnious, and said to refer for this. They said they had seen this and referred. We spoke about leaking amniotic fluid and Dr. Shemaghembe said they need to refer and get antibiotics.

The TBAs said that they, and many of the women, knew that antenatal care was really important, but said that the problem was the husbands. It is expensive to get transport to clinic for those far away. The men say their wives should go for traditional medicine instead. The TBAs suggested solution to this problem was a request for us to train the men too. WTWT agreed to this and we said it could be included in our planned whole community health programme to cover a wide range of health issues: HIV/AIDS/other STDs, FGC, contraception, education before marriage etc.

General health:

We talked about general health being important. I felt that a healthy diet was a painful subject because being healthy and well nourished is a near impossible task in these poor areas. I am aware that not only are they without vegetables due to the ban on growing them and the high cost of buying them in, but they don't even get much of their nourishing milk for three months during the dry seasons. Most of the cows and goats are taken far away to graze, perhaps only leaving one milking cow. This leaves the women and children at home to survive on watery 'porridge' made from maize meal and just a little milk.

Two plants do grow plentifully in the wild, which the doctor said are rich in iron, vitamin A and folic acid: African Nightshade (Mnafu in Swahili) and Wild Amaranthus (Mchicha), so we were able to teach of the importance of including these in their diets. However even these do not grow in the dry seasons.

We asked about the tradition of women being discouraged from eating when they are pregnant in the belief they will have a small baby. They said that they now know this is not good and that they encourage pregnant women to eat as well as they can. We talked about a mixed diet with the different food groups that they can get to eat fairly easily when there is no drought, such as milk, meat, beans, maize and the wild greens.  They are going to discuss whether their Midwives Forum or newly formed Women’s Pastoralist group could start a fund for good food for pregnant women.

The TBAs said they felt it was an important role of theirs to encourage pregnant women to eat as well as they can and to observe what they are eating.

The midwife talked to them about hygiene and the importance of washing their hands after going to the toilet.

15:30 We ended here for day one, with a meal of rice and meat. We ended early because the community had prepared a ceremony for us.

After the meal we went outside for the ceremony put on by the community of Bulati to thank WTWT for their contribution to the completion of their Medical Centre.

After the thanks with music, dancing, prayers and presenting of gifts, there were requests for funding of the furniture and solar panels for the Medical Centre, for microfinance loans and for 2 classrooms towards a school in the remote village of Irmelili over the hills from the other Bulati villages. These people are suffering great hardship.

I was able to reassure them that WTWT had already pledged money for most of these projects and hope to raise enough this year to fulfil their request for at least one classroom.

           Film: warning signs in pregnancy

Day 2. August 6th

Labour and birth:

First we showed the film ’10 steps to a clean delivery’ in a low resource setting. This covered putting a clean folded cloth under the mother for the birth, hand washing for the TBA, putting on gloves for the delivery, the importance of drying the baby quickly and putting it straight onto the mother’s chest and cutting the cord with a new blade. Our TBAs said they do dry the baby well and put him/her on the warm mother’s chest straight away, but were interested to hear about the importance of drying well with one cloth and then wrapping in another. They discussed the composition of different cloths they use, feeling that cotton is better for drying, than man-made fibre, such as polyester, which we agreed with.

Delay in labour

The women said if labour was prolonged they gave hot sour milk to give the mother and baby some strength. We said that if labour is prolonged they should transfer to hospital. Dr. Shemaghembe said they should not use traditional medicine in childbirth, but refer to hospital for problems. 

Cutting

I had heard that the midwives cut the woman’s vaginal opening with a razor blade during delivery to facilitate the birth if it is difficult due to FGC scarring. I was able to ask more about this by drawing a diagram of the female vulva on the board, marking the anus clearly. I then asked them where they made this cut. They showed me, by drawing it on the diagram, a very small nick (1cm long) is sometimes made in the fourchette. I was then able to explain the importance of protecting the perineum and anus from tearing by applying pressure over the anus. I asked if they ever had tears down to the anus, they said they did not. I asked if women were sometime incontinent of faeces after childbirth.  Again they said that they didn’t hear of this. Embapa then told me that these were problems they would not like to admit to because it would reflect badly on them, so I realised that we need to teach how to avoid this.

I asked what they did when women tore. They said that they washed the area with boiled water and then left it to heal itself. We said that if the tear was big or bleeding they should transfer her to the clinic where Dr. Shemaghembe could stich it so that it heals better.

Labour and delivery by TBAs

Next I started acting as a labouring woman and called out one of the TBAs to help me, to get them started. She was a wonderful support, massaging my back firmly and confidently, I felt very reassured.

                   Observing the drama

               

 A team of 4 TBAs then took over and acted out the latter stages of labour and delivery showing us the care they would normally give. The, initially mobile, labouring woman sank onto her hands and knees, and then put her arms around one of the TBAs neck. The three were giving wonderful support and encouragement to the vocalising woman. The 'baby' (a doll) emerged while she was on her knees and the midwife brought it through the front, to the woman's breast, as the other two helped her back into a sitting position. They dried the baby thoroughly and then put another clean dry cloth over the baby on it’s mother’s chest. 

They helped the baby to latch on and suckle. They tied one tie and cut the cord with a razor blade. They told us that they put ash, milk fat or maize flour on the cord end. They then started to apply pressure to the woman’s abdomen to deliver the placenta. We all gave them a big round of applause for their acting ability! This drama gave us a lot to talk about:

                   Drama: delivering the baby

                   Cutting the cord in their drama on the model baby

I said I was impressed by their care in labour and delivery, with the back massage, nurturing of the woman and the good positions she was in. The TBAs said they do not do VEs, so do not introduce infection that way. The doctor and midwife said they would provide gloves for delivieries if the TBAs came to clinic for them.

Cutting of the cord

We then went on to discuss the importance of sterilizing the blade by boiling before using, if it is not a new blade, which they said they are not at the moment. We then said there is no need to put anything on the cord, that putting things on can lead to infection. One woman said that she had seen an infected cord in hospital, that had nothing put on it. Dr Shemaghembe explained that cords can get infected anyway and in this case the baby needs to be taken to the medical centre for treatment. There was a picture of a reddened infected cord base on the delivery film.

Retained placenta

We asked what problems they experience with birth. Many of them said retained placenta was the main problem. We asked what they did in this case. They said they tie a cloth around the woman's waist to help her to push. One TBA said she follows the cord up into the uterus with her hand until she can feel the placenta and then she pulls it way. We advised strongly that she must not do this because there is a high risk of bleeding and infection, which are life threatening. We said she should transfer the woman to the medical centre for the doctor to do this in sterile conditions, where there is IV equipment and oxytocics and antibiotics available.

Physiological Third Stage

I asked the question when they did this tying of the cloth to help the woman deliver the placenta, how soon after delivery? They said they did it immediately, maybe two minutes after birth after the cord is cut. I explained that the normal physiological third stage is a process that takes around 20 minutes and so they don't need to do anything for at least 20 minutes. I talked about the important effect of the baby suckling contracting the muscle of the uterus, and that after about 20 minutes you can feel the uterus contract and rise, if you have your hand gently on the woman’s abdomen. I also said that they would see the cord lengthen at this time and a trickle of blood from the vagina as the placenta separates. They were interested to hear this and said they would wait in future for it to separate naturally.

We also recommended that they do not rush to cut the cord, but can leave it while it is pulsing for the child to get a bit of oxygen that way. It was difficult for our translators translating and explaining all these technical things, they were always talking for considerably longer than the words we gave!

The TBAs said that they do palpate and said they are able to feel if the baby is breech, transverse or if there are twins. They refer for twins and transverse lie, but generally deliver breech babies without problem. The Doctor demonstrated the manoeuvres that we use for breech deliveries, and the women said they did the same. He showed how to bring down the second leg in a footling breech.

Management of PPH

We showed the film: Management of PPH, in which 3 tablets of Misoprostol are given to the woman orally if her blood loss soaks a folded kanga. Help is called and the woman quickly taken to hospital. The women said they did not see it that often, but that if they did they give Olduai traditional medicine. If it does not stop they refer to hospital. We stressed that it was important to get to hospital straight away if the bleeding was heavy. They do not deliver on cloths currently, but on the leather cowhide that they normally sleep on. I drew an area of a pool of blood on the cow hide that would be about 250 mls – a pool of 2 foot in diameter. More than this they should be transferring the woman to hospital after rubbing up a contraction and encouraging her to pass urine. They were familiar with ‘rubbing up contractions’. We encouraged them to use their normal dress cloths folded into 4 to deliver on, so that it is easier to assess the blood loss. If the whole cloth is soaked then the woman should be transferred to hospital.

Dr. Shemaghembe is going to start giving 3 tablets of Misoprostol to pregnant women at their third trimester visit to take orally prophylactically at delivery. We explained that this would contract the uterus and speed up the delivery of the placenta a little. We told them of the possible side effects of nausea, vomiting and shaking, which would be explained to the women when they are given the tablets in clininc.

Caring for the baby

We showed the film: ‘How to Care for a Newborn’, which covered drying well at delivery, the importance of colostrum, and only giving breast milk for 6 months. The doctor also talked about the importance of giving nothing else. Not only because is it protective and provides all nourishment needed, but because giving water, cows milk or maize meal leads to aspirational pneumonia, and he sees this frequently.

 Conclusions and plan:

The end result of our training was that the TBAs are going to encourage all women and their husbands to attend antenatal care from early in their pregnancies. They are now aware of the signs which indicate a woman needs referring in pregnancy, labour and afterwards.

The TBAs will make prompt referrals when there are problems and we will plan with them and Dr. Shemaghembe to have a vehicle always available to take labouring women quickly to hospital when there are problems. 

They were very grateful for the training and said they had learned a lot. They stressed that it is really important for them and they want it to continue on a regular basis. They want 'solidarity with the medical staff and themselves, to work together' which the medical staff agreed to and are keen to do.

They want regular updates on the latest information from the medical staff. They want to form a Women's Forum to address the issues together. They will teach the things they have learned to other TBAs and so improve maternity care. They will teach parents the importance of antenatal care and so increase the take up of this service.

I feel confident that the community will be able to take these things forward, with the support of the medical staff and WTWT.

                                         WTWT employee Embapa, speaking at the Bulati Ceremony

            Midwife Peeiyo and Dr. Shemaghembe outside the completed building of Bulati medical Centre

Post script

During my visit I got some idea about the health care take up by the community:

About 50% of the women currently access antenatal care, though usually this is late in their pregnancy, between 5 and 8 months. The nurse was keen to encourage them to come earlier to enable treatment to have more time to work. Very few are referred to the Health Centre in labour, only about 3 or 4 per month. Most of these are for retained placenta, which Dr Shemaghembe is generally able to deal with by manual removal. Sometimes women come with PPH. In this case he gives Oxytocin, ferrous sulphate, an infusion of saline and a vaginal pack and transfers them to the hospital in Karatu. He hasn't been aware of any maternal deaths during the year he has been there. They are aware of 637 births last year, because those ones came to have a check of the baby after delivery and register the birth.

The doctor makes very few referrals to the hospital in the nearest town, Karatu. Last year it was about 9, some for curetage and some for obstructed labour. Only about 4 needed a Caesarian Section. 

In discussing these issues with our employee Embapa, he said many women will go straight to Karatu if they have a problem in labour, so it is difficult to know things like the CS rate.

Report written by Rachel Blackmore 19^th August 2014