Emma visited Kataru Hospital in Tanzania on a life changing trip
It’s hard to get across just what a profound effect my midwifery elective to Tanzania was – kindly funded by the Cavell Trust Community Award 2015. How can I sum up what a life-changing experience it has had on me and my practice?
I used the award money to travel to Karatu District Hospital, a small rural unit in the northern Arusha district of Tanzania. There, along with a fellow student midwife, I spent 3 weeks observing midwifery and obstetric practice. I have always been interested in women’s health in developing countries, so the opportunity to go out and witness first-hand was quite incredible.
Our daily commute involved taking a small minibus with as many people as possible crammed onto the seats up into the hills, before swapping to an auto-rickshaw to take us to the hospital. The wards (surgical, maternity, paediatric) are housed in a large building with two levels, and there’s also a baby clinic room, a triage area and one operating theatre. Other buildings include a mortuary, laundry, church, canteen, laboratory and pharmacy. There are around ten doctors on staff, who are all general practitioners coping with all sorts of health problems that present. They work with a team of nurse midwives (in Tanzania you train as both), healthcare assistants, cleaners and medical and nursing students. There is also an administrative and facilities team. Every morning there’s a meeting of the senior staff, in which they discuss who was transferred in the night via ambulance (just a Jeep) to the regional hospital in Arusha, and also who died.
The first thing that hit me was – oh my goodness, we’re so lucky in the UK! Then, I suppose I felt a kind of anger that women the world over did not have the same access to basic maternity care standards; it just was so unfair. I was careful to consider the situation from the staff’s perspectives though as it would be easy to just think – well why don’t you clean, or do things this way. But they are faced with massive challenges: there’s no gloves to clean safely with for example, and the books used for teaching are decades out of date. They showed care, compassion and fortitude in the face of some of the most challenging work conditions that must exist for maternity care staff around the world, and for these reasons were an absolute inspiration.
Facilities are extremely basic. In an interview with the hospital head, we were told the annual budget is just USD 1 million, with 75% of that figure going on wages, leaving USD 250,000 to cover the running costs of a district hospital employing around 170 people. Currently there was no budget for all but the most basic life-saving equipment (such as oxytocic drugs in case of postpartum haemorrhage). Women presenting in maternity had to provide their own gloves if they wanted any examinations, and also had to buy their own suture materials, needles, IV fluids and pain relief injections if they were advised to have an elective Caesarean. If they couldn’t they didn’t get one except in an emergency. Some of the machinery in the hospital is very old school – the washing machine was wood-fired and whilst there is an ultrasound machine, it is very old and not used routinely in pregnancy (no gender reveals here or even placental sites!).
Thirty percent of the population the hospital covers are Maasai, who are a semi-nomadic cattle-herding tribe. They are a fascinating culture, but pose specific problems for the hospital in how little they access preventative healthcare and how they – in the words of the hospital director “Tend to do their own thing”. They also practice a lot of FGM. However, to our eyes they and all other tribes in the area were welcomed for medical treatment like anyone else.
The maternity ward in Karatu consists of an entrance hallway with benches outside for dads and relatives, then to one side is the antenatal and vaginal delivery postnatal ward (a long room filled ‘Nightingale style’ with around twelve beds, a few bedside cabinets and a bathroom), and to the other side is an identical room for the Caesarean postnatal beds. Meanwhile directly in front of the entrance is the labour room, sluice and staff room. Each ante/postnatal bed has a mosquito net, but there are no dividers between beds. Every morning the students clean the ward floors, make up the delivery packs for autoclave and prepare for the doctor’s round. This is done from bed to bed, with around 15 students following; this is considered a teaching occasion so the woman will be publically discussed and examined with everyone listening, including the other women. Sometimes a screen is used but mostly not. A big shock for us was just how dirty everything was – there was blood and other body fluids on all of the delivery beds despite them being perfunctorily ‘cleaned’ after each birth. However, with no gloves, hot water or soap, cleaning well was a tall order for staff...
Women in spontaneous labour are pretty much just left lying on a dirty bed to get on with it. There’s no pain relief at all, no labour care as we understand it, no observations, no monitoring, and little documentation! One poor woman was a first-time mum in agonising back-to-back labour for hours and hours with no analgesia. When women are ready to push, they lie flat on their backs (even though this is bad for mum’s blood supply to baby), feet to hips and are given about half an hour before intervention. A lot of the women we saw had FGC (female genital cutting); this made things like examinations or catheterisation very hard and painful. At the point of delivery a midwife or student will don a large plastic apron, stand on a box to reach the bed and wait to catch.
Woman and babies I will always remember
Some of the women and babies we met will stay in my mind as long as I can remember. I want to share some of these stories with you, because I think it makes you realise how lucky we are both as clinical practitioners and clients of the NHS.
A woman who really touched us was a Maasai lady of around 18 years old who was carried in by her husband and a friend for tens of kilometres after her placenta was retained inside her after she delivered a stillborn baby at home. She was prescribed an injection of Anti-D to stop her body rejecting her next baby because of her Rhesus negative blood type – we went away over the weekend and just assumed she’d receive it. On Monday’s ward round we were devastated to find out she hadn’t received it because her family couldn’t afford to buy the Anti-D (USD 100). We of course offered to pay but we were too late; that woman may also lose her next child and her husband potentially will not support her after three losses.
Another Maasai woman we saw had full-blown eclampsia at 23 weeks and had fitted twice at home before being brought in; at home she would be under intensive observation, with all the tests possible, constant monitoring of her baby etc. Her blood pressure was checked every 4 hours in Karatu, and whilst the medical students were ordered to dip her urine for protein (they don’t have PCR tests available) they forgot so the doctors had to chase it up later that day.
One woman we heard about had been given an elective caesarean for some reason and when they opened her up to get the baby out they realised she had twins!
Positive things and the future
The midwives, students and doctors we met were on the whole absolutely lovely people. They were all very committed to their work and learning. The students have only a few outdated textbooks to share between their whole year but want to know as much as possible. Everyone was interested in sharing perspectives and finding out about how we work in the UK. The doctors were knowledgeable and very caring; they were careful to obtain consent and explain what they wanted to do and expected their students to do the same. They want to give their best but don’t have the education or resources often to do this. It is not fair to judge the hospital by UK standards in most respects because the means to practise as we do simply don’t exist.
The hospital was absolutely over the moon with the gifts we provided, especially the Ambubag resuscitation bits and the Doppler fetal monitors. They thanked everyone who donated from the bottom of their hearts.
When I got home, the first thing I did was write a frank report and share it amongst all my friends who fundraised the £500 for all the equipment we took out with us. I wanted to get across all I had seen to them. I have plans to ensure a long-term link between my university – Oxford Brookes – and Karatu midwifery/medical training school, but it’s hard to get the motivation back in the UK from people who don’t have the emotional link like myself. I have had interest though, which is great. I’ve promoted the elective opportunity to the years below me, and will also promote it to the other healthcare disciplines at our faculty. The Karatu Hospital were very keen to get more volunteers.
Claire and I hope to set up a charity to fund people from the hospital – doctors, midwives and students – to visit the John Radcliffe. We hope this will facilitate education and knowledge exchange.