Today's "Birth Around the World" feature is a guest post by Pauline of
Infomidwife. Pauline is an independent midwife in Australia.
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This is a snapshot of midwifery in Tanzania from my perspective. It does not refer to anyone specific; the judgments are made from my personal observations.
Tanzania is a country in which health resources are minimal and much help is required--the lack of staff, general caring, and privacy being high on the agenda.
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| Clean room |
In the public hospital the labor ward has approx 12-14 beds. The beds are hard and there is no visible linen. The windows and doors remain open and there is a problem with flies. I did notice curtains around some of the beds, but they are rarely used. The ward is split into three sections with a resuscitation area for the babies; however, I did not see any resuscitation equipment.
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| Labor bed |
There is a long wooden bench for the women to sit on after birth, and there is a clean and dirty room. However, it is a stretch of the imagination. There is a small room attached that has four beds and this is called the eclampsia ward. The incidence of eclampsia appears to be high, and the antenatal care is insufficient in the prevention of the condition. This could be due to the low resources, therefore not enough education. There are some rudimentary posters on the walls for treatment of PPH and eclampsia. Generally the ward is constantly busy, noisy, and often used as a thoroughfare.
A normal 24hrs could see anywhere from 74 – 120 births. On the days I spent there, the average birth rate over 24hrs was 75-85 births--a quiet time. The lack of staff is a massive problem and the ward is laden with students. As I commented in my nursing in Tanzania blog, the structure of nursing is very different to Australia. Nursing and midwifery are together in every course and I suppose this also will assist with the shortage of staff.
Just to remind you of the career structure: enrolled nursing & midwifery is now a 2 yr course (previously 4yrs). Entry level is equivalent to yr 10 (form IV). As student midwives, these students conduct 20 normal births and 10 high risk (breach, face, brow presentations etc) supervised by a qualified midwife. Diploma nurses and midwives, if they have moved up from enrolled nurses, will do a further 10 normal births and 5 high risk, and this takes a further 1 yr, also supervised by a qualified midwife. Diploma nurses/midwives straight from school good scores for form IV, three yr course. These nurse/midwives, if they want to convert to a degree course, will have to do another 3 yrs (6yrs in total). Lastly there are degree nurses and midwives (3yrs course) entry level form VI (TEE / TER level) these students require 30 normal and 15 high risk births. Confused? It took me a while to work it out.
Part of the problem is that students outnumber the registered staff. You don’t know who is an enrolled /diploma or degree nurse/midwife student until you ask, and then I was still not clear who is accountable for what. On my shift there were 6 students and 2 registered nurse/midwives and a doctor. At one stage I had four labouring women at fully [dilated] with just me myself and I. Oh, and my nursing students (as if in a maternity setting). It was frantic.
The African women need to bring with them 4 Kangas; these are traditional cloth /dress, pieces of material 2 meters long. One piece is cut in half, so there are two for the baby. The women use one as a sheet on the bed. They often have one they are wearing, and the others are for after the birth and the baby. Often the women are naked; privacy does not seem to be an issue. People walking in and out of the labor ward as if it was a thoroughfare.
Flies were annoying. It was hot/humid; everyone was sweating, no way of cooling down. There was no visible water anywhere. At times I felt useless and helpless. I allocated my nursing students to stay with each woman, attempting to provide some comfort and encouraging them to drink some water, which the women bring in themselves. I found a Pinard [wooden stethoscope] on the desk and was showing the students how to use one. There was no electrical fetal monitoring (not such a bad thing).
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| Delivery pack |
Two women had syntocinon [Pitocin] running, so I listened to their fetal hearts first. All seemed well. Then I moved to the second two women. These two seemed to be going head to head as to who was going to deliver first. I called out for some help, and a doctor came forward. He was less than helpful; however, he did yell for someone else to assist. Whilst he was with me, I asked if he could translate to my women as I wanted her to stand up or turn over to aid her birth. His response was “no, we like them on their backs so we can see what is happening.” He promptly called for a student midwife to assist me and yelled at the women to push harder. I regretted asking him to translate.
As we were preparing for birth, I found the delivery pack but could not find a cord clamp. By now the woman was pushing well. The student midwife had disappeared momentarily, so I asked my favourite doctor who had taken his spot at the desk--watching the events, no curtains, three naked women in the room all pushing--"excuse me, I can’t find a cord clamp." "Ah, you want a cordie clampie. Ask the woman or look in her bag, she has them.” Now the student has returned and I am informed that the women bring in a cord clamp, a roll of cotton wool for the birth, her Kangas, and food and water for herself. If the woman does not have a cord clamp, you find some cotton or tear a piece of material to tie the cord. Thankfully the woman had purchased a cordie clampie. I could not find the scissors to cut the cord.
Emm that’s because we use a blade. At one stage I needed to clean around the perineum and asked my student nurse for a paper towel, forgetting where I was. (The poor student went looking for one until I called
sorry forgot where we are. We both nervously laughed.) It was tough to use cotton wool for everything. It is hard doing a vaginal examination using cotton wool.
It was a beautiful birth, a truly special moment. Third stage went well, syntocinon given as usual. The woman was exhausted. Now it was time for her to get up and go and sit on the bench. I had taken too long, and the student midwife was hurrying me along. It was only 40mins after the birth. The student midwife cleaned the bed with the two dirty Kangas. I asked, "what happens to them now?” She continued to clean the bed, rolled them up, put them in a plastic bag and gave them back to the woman. No laundry required. The woman sat on the bench, drank her water, and had a bite to eat (a piece of bread I think) and started breastfeeding.
We then weighed the baby. The woman was then transferred to the postnatal ward (we walked her across) within 90mins. She then stays on the ward for 6hrs and walks home or catches the bus with her baby. The postnatal ward may have two or three women to a bed. I counted 12 beds, saw no baby cots. The women lay exhausted on the bed with their babies, some crying, soulful eyes watching you. They have a resigned look on their faces as if
this is my life. The nurse is sitting at the desk. The ward is packed a sea of faces. There were be a couple of nursing assistants walking around assisting with breastfeeding. It was heartbreaking, poignant, and I was saddened by the obvious pain of life.
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| Resuscitation bed |
It wasn’t long before there were two more babies, all healthy and well. The last woman was having difficulty and was going for a Cesarean section. They don’t have forceps or ventouse [vacuum] births in this hospital; however, I could see the benefit of using a kiwi cup...but that’s a different story. The Cesarean section rate is about 20% and on the increase. Only about 40% of women birth in the hospitals; the rest are out in the rural areas.
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| Traditional Birth Attendants |
We did visit a dispensary that was well-equipped for births. I met some traditional birth attendants, who also stated that they birth women on their backs on the floor. I did find this interesting. I tried to share my experience of changing positions and it was met with great laughter.
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| Transport poster rural area |
In the rural clinic the women come whenever they have time or feel they need to attend. With their first babies they seem to be more vigilant. Clearly, the more babies they have the less inclined they are to come to the clinic early. They normally show up at about 32 weeks. The clinic we visited was 2.5 hours away from the hospital, and transport if things go wrong is difficult. They often have to cope or find alternative ways of getting to the hospital.
My students really enjoyed this placement and I am sure that 4/5 students will go on to do their midwifery. For me I was dismayed and the visions stayed with me for days. I am still troubled by the conditions that women are in, and I would be keen to be able to help in a more substantial way. The issues that struck me most:
- Technology v no technology
- Caring / compassion v no caring / compassion
- Women being totally alone with no support
- The total lack of staff
- Birth flat on their back in bed
There was a complete contrast in the private hospital. The birth rate for November was approximately 50 for the month. There were no patients on the day we spent several hours there. Privacy is still an issue with three labour beds in the one room. The labor ward has just been renovated so was very modern.
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| beds in the private hospital |
There were brand new beds. However, I was disheartened when I saw the strips remain in place on the bed. For me, this would mean
because they are there they will be used. There was a CTG [EFM] machine. In another room there were two labor beds, and there was one private room (the executive room, of course at a price). What was surprising was they had a spa bath. It was great to see. However, they would need education regarding its use. (I was asked to give a lecture on waterbirth, but that’s another blog). There seemed to be more staff here, and they did seem more caring and provided one-to-one care. But this was only a snapshot, so I really could not give an accurate account. It was reassuring but sad at the same time, because most women could not afford this care.
My maternity time was an experience, as was my whole Tanzanian clinical practice. I met some phenomenal people and some I hope to continue to keep in contact with... more in my next blog.
