7 September 2013

Tanzania: Maisha Programme Cuts Maternal Deaths

IT was late in the evening, a nurse-midwife; Ms Neema Mlunza had just begun her evening shift at her working station, the Idodi Health Centre in the Southern highlands of Tanzania.

The nurse-midwife's first patient is a mother of four who is HIV-positive. She was in labour waiting to deliver. As the expectant mother gave her last push, Mlunza had to guide her for safe delivery of the baby. Due to careful guidance from the nurse-midwife, who had received further skills from the Jhpiego's MAISHA programme on how to take care of such kind of patients, the expectant mother safely delivered a free from HIV/ Aids infection boy.

Jhpiego is an international non-profit health organisation affiliated with the US Johns Hopkins University. A minute after delivery and check up which follow all national clinical protocols, a nurse-midwife gave the mother a shot of Oxytocin to help the uterus contract and started delivering the placenta.

Despite following these standard steps, unfortunately, the mother started bleeding uncontrollably and this forced the nurse-midwife to rethink and immediately find solution by applying skills she acquired from the Jhpiego's MAISHA programme.

Ms Mlunza, who trained under MAISHA programme on postpartum hemorrhage; newborn mortality due to infection; prevalence of low birth weight babies, stillbirths and newborn mortality due to malaria and congenital syphilis; and the number of HIV infections transmitted from mother to child recalled something was not right. She found out that the uterus had not contracted.

She calmed down the mother and explained to her on what was going on and the steps, she had to take so as to stop the bleeding as soon as possible. She quickly applied some techniques she acquired during the training, at last she managed to stop bleeding, which after birth can quickly lead to shock and death if uncontrolled.

The case stresses the importance for health care providers to be prepared to handle cases of postpartum hemorrhage. In Tanzania, postpartum hemorrhage - excessive blood loss within 24 hours after childbirth - is the most frequent cause of maternal deaths, accounting for nearly a third of all 13,000 pregnancy- related death occurring yearly.

The patients such as the one in this case are exactly the kind of women that the Jhpiego-led Mothers and Infants, Safe, Healthy and Alive (MAISHA) programme is working to reach. Under this programme, Jhpiego works with the Ministry of Health and Social Welfare to reduce maternal and newborn deaths by equipping health care providers such as Mlunza with skills to make the right decisions and take appropriate actions in time.

"With my surgical gloves on, I inserted my right hand into the birth canal to compress the lower part of the uterus. And then I placed my left hand on the abdomen and applied compression for five minutes," she said. "After releasing, I felt something pulling... ..the uterus was contracting... the bleeding was slowing down, and after a few minutes, it stopped altogether," she noted.

After making sure there was no more bleeding, Mlunza placed the swaddled newborn on the mother's chest for the skin-to-skin contact that is essential to begin the bonding process -another lesson learned in her training. "We stayed with the mother and new baby boy for 24 hours," Mlunza said.

"In the meantime, I gave the newborn nevirapine for HIV prophylaxis and made sure the mother completed all the doses for prevention of mother-to-child transmission of HIV." To minimise the risk of transmission through breast milk, all HIV-exposed infants should receive antiretroviral prophylaxis, which in Tanzania is nevirapine until one week after cessation of breast-feeding.

Mothers in Tanzania are counselled to exclusively breastfeed their infants for the first six months, followed by the introduction of complementary feeding with continued breastfeeding until 12 months of age. When the mother and child recently visited the clinic, Mlunza was thrilled to see them.

"I keep following up on their progress. Mother and child are doing very well. The confirmatory HIV test results for the baby came out. He was negative. And the mother - she does not miss her clinic days at our HIV care and treatment centre," the nurse-midwife said proudly.

"Without the new skills I acquired from the MAISHA BEmONC training, we were going to lose this woman," said Mlunza. "We have lost many (women) like her in the past. But now through me, nine of the 13 health providers at the health centre have acquired these lifesaving skills--starting with my husband, (the clinical officer)--who was amazed how I was able to do this with confidence."

Supported by the US Agency for International Development, MAISHA is one of the many innovative programmes through which Jhpiego works to prevent the needless deaths of women and families in Tanzania. In countries such as Tanzania with high numbers of maternal deaths and limited resources, introducing lowcost, evidence-based practices to handle birth complications such as postpartum hemorrhage is an important way to improve and save lives.

MAISHA introduced these evidence-based practices by providing competencybased training in basic emergency obstetric and newborn care (BEmONC), as well as equipment and supplies, to 771 nurse-midwives in Tanzania. As a result of this training, Mlunza knew she needed to move quickly when the mother began to bleed uncontrollably. She ran an intravenous line with Ringer's lactate solution and injected the mother with the appropriate amount of additional oxytocin to help replace lost body fluids and contain the bleeding.

Mlunza then began to apply external compression by massaging the woman's abdomen with her hands to help the uterus contract and stop the bleeding. But the bleeding continued. She needed a second pair of hands and called for the clinical officer on duty, who happened to be her husband.

As he monitored the mother's vital signs - the woman's blood pressure had fallen dangerously low and her pulse rate was very high - Mlunza switched course and began internal compression of the woman's uterus to try and stanch the flow. Talking to the mother in a comforting tone, she continued applying the lifesaving skills, she had learned.

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