Tanzania Daily News (Dar es Salaam)

1 December 2012

Tanzania: Doctor Takes on Maternal Mortality

IF it were in Christianity, a doctor in Kigoma town jokingly said recently, Dr Godfrey Mbaruku would be revered as another Jesus Christ, for saving the region's pregnant women from being depleted by maternal mortality.

Before his arrival in Kigoma in 1987, Dr Mbaruku, then a young gynaecologist, but now deputy director with Ifakara Health Institute, most health facilities now available in the region were non-existent. Like in most parts of the country at that time, pregnant women, especially those who lived in rural areas, didn't have access to crucial health services.

Maternal mortality outrageously stood at 933 per 100,000 live births in the region as women died of excessive bleeding and obstructed labour because they had to travel long distances to reach regional and district hospitals to get skilled health services. Even then, women who managed to arrive at the health services after experiencing labour for three days would receive limited specialized services, because such hospitals faced shortage of supplies while some of those who opted to deliver at home died.

"It was such a heart-rending situation that I began regretting why I had accepted the post," Dr Mbaruku slowly recalls during an interview. He understood quite well that it wasn't easy to change the situation overnight, especially without the support of the communities around the Kigoma Regional hospital and most importantly, health workers who were dreadfully unmotivated.

During the interview, Dr Mbaruku doesn't stop telling a story which, he says, typifies how saving a mother's life takes more than one perfectly done thing. Early one morning in 1989 when he was taking a shower readying himself to go to work, he narrates, a nurse from the hospital knocked on his door.

A bleeding pregnant woman had been brought to the hospital. It was her sixth pregnancy and her condition had not improved even after the nurses had attempted to provide her with treatment. Dr Mbaruku knew pretty well that there wasn't time to waste and with soap bubbles still all over his body he rushed to the hospital's maternity ward. The medical team embarked on a mission to save the woman's life, employing every they knew to do so.

It wasn't after she had been supplied with eight units of blood and four hours of frantic work that the woman and her baby survived. "I know the woman even today," Dr Mbaruku says, adding, "And she has never stopped thanking me." The pregnant mother's experience taught Dr Mbaruku the importance of a hospital having staff housing within its compound. With the help of his colleagues at the hospital, Dr Mbaruku came up with 22 interventions which involved building housing for key health workers who would be required to attend to patients in case of emergency at night.

An anaesthetist, laboratory technician, surgeon and pharmacist stayed within the hospital compound. When he was first introduced to the communities upon his arrival, most of them complained about nurses at the hospital being rude to patients. He later realized that most of the complaints were in fact directed at some health workers who had worked in the labour ward for over ten years and so found their duties monotonous and unrewarding.

"So, we transferred them to other departments and it made a difference," Dr Mbaruku says. For example, he says, health workers had to collect water for use at the hospital from Lake Tanganyika because the water tank was broken. The tank was renovated and the availability of water meant that there was enough water to provide better services to the patients because even health workers had more time to attend to the patients rather than go to fetch water. "I started advocating teamwork and motivating employees," says Dr Mbaruku.

The hospital was also consistently running out of essential drugs, leading to the deaths of mothers. Besides, it took a long time for a new consignment of drugs to reach them. We decided to set up a small separate room where we would store essential drugs so we would have drugs for mothers when we ran out of normal supply," recalls Dr Mbaruku. Apart from introducing on-job training for unskilled health workers at the hospital, Dr Mbaruku says, the hospital also established a small blood bank and started offering blood transfusion to patients.

Before the service was introduced, he recollects, pregnant mothers were asked to go to hospital with their relatives so they could donate blood for them when their delivery dates were due. When the regional hospital's maternity ward was rehabilitated, Dr Mbaruku says, regular audit-oriented meetings were introduced. It was at such meetings where challenges facing health workers were discussed.

"This helped to raise the morale of workers because they felt important. They, in turn, started attending to patients better and soon the news spread to the district hospitals and most people started flocking in the hospital because they knew the services were better," says Dr Mbaruku. The results indicate that the maternal mortality ratio fell from 933 to 186 per 100 000 live births during the almost two decades Dr Mbaruku worked in Kigoma region. This therefore goes to show that the problem of maternal mortality can successfully be tackled through a low-cost intervention programme, aiming at identifying issues of avoidability and focusing on local solutions.

However, Dr Mbaruku believes that the interventions used in Kigoma region to reduce maternal deaths could be used elsewhere in the country and produce similar results. The environment could be different, he says, but the problem would still be the same. "This is what areas with high maternal deaths can do instead of pointing accusing fingers at each other or the Ministry of Health and Social Welfare," he says. Because of his work in the region, most health workers see him as a hero and a person who showed and taught them how simple methods could yield positive changes.

Dr Mbaruku thinks that if communities, hospitals and health centres worked together they would definitely reduce maternal deaths. He advises communities around health centres to help provide housing facilities to health workers. Kigoma region is a success story because it has strived to bring essential health services closer to the people, Dr Mbaruku says, adding that since the majority of Tanzanians live in rural areas it is a big joke to think that they would be able to access health services at regional and district hospitals, which in most cases are located far from their villages.

"Since there are health centres in almost all strategic areas in the country, we should strive to improve them by providing more staff and equipment so they can provide quality health services to the people," he says. At 578 deaths per 100,000 live births, Tanzania is said to have one of the highest maternal death rates in sub-Saharan Africa and Dr Mbaruku thinks that it is because an assessment has not been carried out recently.

He thinks the maternal death rate has generally levelled off, if not actually declined, because the problem has of late been given by the government the attention it deserves. He cites a maternity ward at Mwananyamala district hospital which was built in 1983 when the population of Dar es Salaam region was less than two million people, to date, the building has remained the same.

This is despite the country having the best health and development policies in place but lacking in action and commitment, according to Dr Mbaruku. He strongly feels that maternal mortality should be fought on all fronts because good doctors need good equipment and health facilities for them to deliver on reducing maternal deaths. He says although people living in rural areas are generally perceived to be illiterate, they are certainly not so stupid as not to know where to access quality services.

"When a woman goes to a health centre and finds that there are no doctors and the services are bad, she will inform all her neighbours and eventually the entire village will know. Consequently, nobody will want to go to that health centre again and pregnant women, when they want to deliver, will opt to be serviced by traditional birth attendants (TBAs). Recently, activists have been pushing the government to increase the health budget to 15 per cent as stipulated in the Abuja Plan of Action, but Dr Mbaruku knows some countries which have actually met the 15 per cent pledge but have not managed to reduce maternal deaths.

That is why Dr Mbaruku is convinced that what is really required of policy makers before increasing the allocation is to come up with proper plans on how the money will be used. "You may allocate 15 per cent of the budget to health but realize that five per cent of the amount will be used to fund seminars," Dr Mbaruku says. He further calls on councils to change the computerized system which allocates money depending on the gravity of a particular disease.

Dr Mbaruku says that, according to the system, if a council has more malaria patients, more funds will be allocated to malaria control programmes. In most circumstances, he says, maternal and child health funds are combined, meaning that more money may go to children vaccination programmes rather than to maternal health.

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