Saturday, February 23, 2013

DEATH IN BIRTH


             BEREGA, Tanzania — The young woman had already been in labor for two days by the time she reached the hospital here. Now two lives were at risk, and there was no choice but to operate and take the baby right away.
It was just before dawn, and the operating room, powered by a rumbling generator, was the only spot of light in this village of mud huts and maize fields. A mask with a frayed cord was fastened over the woman’s face. Moments later the cloying smell of ether filled the room, and then Emmanuel Makanza picked up his instruments and made the first cut for a Caesarean section.
               Mr. Makanza is not a doctor, a fact that illustrates both the desperation and the creativity of Tanzanians fighting to reduce the number of deaths and injuries among pregnant women and infants.
Pregnancy and childbirth kill more than 536,000 women a year, more than half of them in Africa, according to the World Health Organization.
Most of the deaths are preventable, with basic obstetrical care. Tanzania, with roughly 13,000 deaths annually, has neither the best nor the worst record in Africa. Although it is politically stable, it is also one of the world’s poorest countries, suffering from almost every problem that contributes to high maternal death rates — shortages of doctors, nurses, drugs, equipment, roads and transportation.
               There is no single solution for a problem with so many facets, and hospital officials in Berega are trying many things at once. The 120-bed hospital here — a typical rural hospital in a largely rural nation — is a case study in the efforts being made around Africa to reduce deaths in childbirth.

             One stopgap measure has been to train assistant medical officers like Mr. Makanza, whose basic schooling is similar to that of physicians’ assistants in the United States, to perform Caesareans and certain other operations. Tanzania is also struggling to train more assistants and midwives, build more clinics and nursing schools, provide housing to attract doctors and nurses to rural areas and provide places for pregnant women to stay near hospitals so that they can make it to the labor ward on time.
              But there is a shortage of Emmanuel Makanzas, too. As he began to operate, he said he should have had another pair of skilled hands to assist him. But, he said, “we are few.”
He made a quick, vertical cut, working down from just below the navel, through one layer at a time: skin, fat, muscle, the peritoneal membrane. Within three or four minutes he had reached the uterus, sliced it open and wrestled out a limp, silent baby boy exhausted by the prolonged labor and knocked out by ether. It took a nurse 5 to 10 minutes of vigorous resuscitation to get him breathing normally and crying.
             There are many nights like this at the hospital here, 6 miles from the nearest paved road and 25 miles from the last electric pole. It is not uncommon for a woman in labor to arrive after a daylong, bone-rattling ride on the back of a bicycle or motorcycle, sometimes with the arm or leg of her unborn child already emerging from her body.
              Some arrive too late. In October, a mother who had been in labor for two days died of infection. In November and December, two bled to death. Doctors say they think that more deaths probably occur outside the hospital among the many women who try to give birth at home.
                A few minutes’ walk from the hospital is an orphanage that sums up the realities here: it is home to 20 children, all under 3, nearly all of whose mothers died giving birth to them.
“You can never get used to maternal deaths,” said Dr. Siriel Nanzia Massawe, an obstetrician and the director of postgraduate studies at Muhimbili University of Health and Allied Sciences in Dar es Salaam, the country’s largest city. “One minute she’s talking with her husband, then she is bleeding and then she is gone. She’s gone, very young. You cannot sleep for one week. That face will always come back to you. Too many die, too young. But the people in power, they have not seen it. We need to make them aware.”
                 Over the course of several days at Berega, the difficulties became clear. At times, Mr. Makanza performed one Caesarean after another, sometimes in the middle of the night. One mother was only 15. Another had already had two Caesareans, adding to the risk of this operation or any future pregnancies, but she declined Mr. Makanza’s recommendation to be sterilized.
                  Others had hoped to speed their labor by taking herbal medicine but were suffering dangerously strong contractions. Hospital staff members struggled to keep up with the operations, handwashing bloodstained gauze and surgical drapes in basins and mopping blood from the floor between cases.
Two women had severe problems from high blood pressure. One came to the hospital after giving birth at home and having a seizure. Another delivered a full-term infant who had died in her womb at least a week before; her only other pregnancy had ended the same way.
A mother in the maternity ward had arrived in labor with twins, one already dead. A Caesarean had saved the second.
         The Global Perspective
           Women in Africa have some of the world’s highest death rates in pregnancy and during childbirth. For each woman who dies, 20 others suffer from serious complications, according to the W.H.O. “Maternal deaths have remained stubbornly intractable” for two decades, Unicef reported last year. In 2000, the United Nations set a goal to reduce the deaths by 75 percent by 2015. It is a goal that few poor countries are expected to reach.

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