Third Trimester….

 

Hard to believe that I am in my 7th month! (of volunteering, that is.)   The end of my work here is in sight, and my safe delivery back to Canada in July.  It has been an eye-opening experience. I am so glad that I came.  But I will be ready to return – 9 months is a long time to be away from family, and so much has gone on both here and there!

You may have wondered why the recent radio silence in my blog….like confinement when your “condition” became obvious, in pregnancies long ago.  Well, it was something like that. The government of President Magufuli passed a law requiring bloggers to register with them, pay the equivalent of $900 USD, and be monitored. So I stopped writing, as I couldn’t meet all the criteria (register as a company, provide names of company directors, proof of payments, etc.) and I certainly didn’t want to be on the wrong side of the law. Many local bloggers shut down as well.  Just last week, the High Court held that the law was not legal as currently written, so I am writing quickly while the window is still open!IMG_2570

I continue to try to see as much of Tanzania as I can, for work and pleasure. Quick travel update:

We were extremely lucky at Gombe Stream National Park, seeing over 13 chimpanzees – some at ground level, very close to us, others in low trees and many up high.

 

 

 

Then (after doing some real work for a while) I flew to Mafia Island for yet another yoga retreat and snorkelling excursion. As with many things, I sometimes see things differently from others  – left legged tree pose anyone? We had fun.

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Then to Dodoma, the capital city of Tanzania, for the Nursing and Midwifery Scientific conference – over 3/4 of the juried presentations were on midwifery!  Our booth, with the Mama Natale simulated birthing demonstrations, was very popular. Shoulder dystocia, breech birth, resuscitating a newborn – emergencies that midwives must learn to address, as they work in remote locations with no back-ups.

Then all efforts were on preparation for the International Day of the Midwife celebrations – this year in Morogoro – from May 2 – 5.  The first few days emphasized free clinics in a local park – HIV AIDS testing and counselling, family planning, youth friendly services, wellness tests (blood pressure, weight, diabetes, etc.). Then Saturday was the Climax Day, with dignitaries from the International Confederation of Midwives, Sanofi Foundation, Canadian Association of Midwives and local government representatives being entertained by a rally led by a marching band, then local dancers and a choir. We then heard from them on the benefits and goals of midwifery in Tanzania.

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A new room mate, Suzanna, has arrived to do organizational planning/capacity building, and Patricia (Communications) leaves in a week.  Then Mahad (Monitoring & Evaluation/data collection) arrives in early June. So many adjustments as we all get used to each other and divy up the work that Patricia had been handling.

The three volunteers: Nance, Patricia and Suzanna

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I have booked what is likely my last excursion here – to the Buddhist Retreat Centre in Ixopo, South Africa (near Durban) for a week at the end of June. It will be yoga, meditation and silence….I hope it will allow me to reflect on my year and consolidate what I have felt and learned.

Then I will be on my way home a few weeks later!

 

 

 

 

 

 

 

 

 

 

Getting there is half the fun?

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Kigoma Harbour

Gombe Stream safari:

So, in our attempts to see as many different facets of Tanzania as possible in our time here, on Good Friday Patricia and I got up at 3 a.m. for a 3:30 taxi to the airport. After a two hour flight we landed in Kigoma, in the north west corner of the country, on the shores of Lake Tanganika. (The Democratic Republic of Congo and Burundi are on the other side of the lake, so many refugees cross the lake to Tanzania. There are 3 refugee camps in or near Kigoma.)

Tomu, our cook for the next 3 days, greeted us. A ten minute drive got us to the harbour where we boarded a covered, largish wooden motor boat. All our luggage, the food Tomu had ordered and a propane tank cookstove were loaded. There is no food available in the park.

The boat’s engine was not running smoothly for what was supposed to be a 2 hour boat ride northbound along the east bank of the lake (on a very pleasant day) to the park. It chugged along on what sounded like three cylinders. We passed ferry loads of workers coming south from the park to the town for a day off, all in bright orange life jackets, saw many little villages spaced along the shore, and many fishermen, until we crossed into the Gombe Stream National Park. Then signs of humans became extremely limited. Fishing and hunting (by humans) are prohibited.

B719B500-5D1E-4171-994D-77292183B074About 15 minutes by boat from camp, I thought the sputtering engine finally would conk out….and it did, but not the way I expected! We hit a rock and the motor fell into the lake.

Luckily it was tied on and the helper (who had been driving while the Captain slept) kept hold of the handle. However the motor was immersed… and once out, it refused to start (no surprise). I wasn’t sure how the story would go from there, as we were far from any villages and there were no other boats in sight. As we waited while the Captain took apart the engine, we watched brilliant blue butterflies sitting on the beach eating, fluttering their wings, rising briefly off the sand whenever a wave came. The rocks were granite, like in Muskoka, only smoothed, with pebble beaches.  Little rivers flowed out from the woods. Baboons also searched the sand for food.

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Ripples on pebbles

It became clear that the boat was going nowhere without help…and none was to be seen. So Captain Baraka, going above and beyond the call of duty, jumped into the water and pulled the boat along the shore for over 1.5 hours, with his helper keeping the stern of the boat off the rocks with a paddle. Luckily it was a gently sloped shoreline. Every once in a while he would need to cool off by diving under water, then went back to guiding the boat along the shore. We knew we were nearing the camp when we saw  hikers in the woods: relief all around.

Once we arrived at Gombe, Baraka arranged to transport the motor to the nearest village, as it would need to be repaired to make the return trip.  Not having a boat meant a bit more walking for us, as we sought out where the chimps were. Luckily, just after we arrived and started hiking, two chimps,  Fudge and Tomu, came CHARGING down the path after some baboons , then started calling and drumming, apparently to gather their clan. Very exciting! The day ended at the waterfall, with a standing rainbow.A12AA8CA-2875-4A97-88E2-E078CF388A81

 

In honour of World Water Day, March 22nd

IMG_20180203_135021.jpgOK, so I am a few days late, but it has been busy! And it really should be World Water Month …or  Year.  It is hard to wrap your mind around the seriousness of this day, living, as many of us do, in countries where we take clean drinking water for granted.  However, here in Dar es Salaam the papers are full of stories of people in Cape Town, South Africa  lining up for rationed water, with pipes to their homes shut off. In addition, it is not just water – in many places, including here, it is the aging (or limited) infrastructure to deliver the water. While we have water in our taps (most of the time), it is not drinkable, with possible bacterial contamination.  And we are lucky to have that water. Many must access water from public taps or wells, carrying water bottles on their heads, on bicycle carts or using donkeys.

To drink any of the tap or well water, it must be boiled for 10 minutes, then strained through a clay filter.  But boiling takes time (gas or electricity – and the latter is really expensive…or charcoal or wood fires if the home has neither gas nor electricity).

Luckily (?) bottled water is very cheap – 20 litres for 6 TzS (approx. $3USD), including delivery, in a resuseable plastic bottle, but you have to  pay a $20. deposit per bottle. Not everyone can afford the deposit on the big jugs, so there are many smaller sized bottles – recycled if they get thrown out.

But there are many other ways the plastic bottles or jugs are used before they make their last trip to the dump. A few examples:  cut off the top, use the top as a funnel and the bottom as a garbage can, planter or pail, smaller ones become glasses or vases; fill with sand, recap, lay it sideways and use it as a building block; use to get water from the well (below, right); street light cover (below, left); and use the different coloured caps as checkers squails.

Here, as everywhere, the bottles find their way into the ocean. There is a regular beach clean-up day by volunteers, only to have more bottles appear. On streets, collectors gather the bottles to take to recycling where they get a small fee. There is no separation of recyclables at the home. Rather, the garbage collectors tear open the garbage bags in the trucks and remove the plastics. It is a smelly job, but keeps plastics out of the landfill.

So, we face issues of availability, access, infrastructure and plastic being used because there is no other way to get clean water.  At least in Canada we can choose not to use plastic bottles.

An even larger issue is migration due to climate change. It  is already occurring with much more to come. Lots to think about around World Water Day.

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And some wishful thinking below.  I hope you have a thoughtful World Water Day.

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We want to give our best, but what is it? Things are not as easy as we may think….

 

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sign on how to resuscitate a baby

When recently in Simiyu, Lake Zone, Tanzania, I met a program assessor from a donor country. When I mentioned that the Tanzania Midwives Association (TAMA) had a 5 day Midwives Emergency Skills Training, she commented that it was not the “standard” 15 day Comprehensive Emergency Obstetric and Neonatal Care (CEmONC), or even the 12 day Basic Emergency Obstetric and Neonatal Care (BEmONC), and thus might not be considered for funding using their criteria. On the face of it – why wouldn’t donors only want to provide the most comprehensive training?

My conclusion is that, if the emergency skills training was taught while the midwife was still in school, great. But at the moment, it is not. (see earlier blog). I continued to ask questions at the small health facilities I was visiting, and among TAMA members, to determine the benefits of a shorter program.

It came down to 3 factors:

  • Availability of replacement staff when a midwife leaves for training;
  • The most common emergencies at the basic level of facility;
  • How people learn.

Most facilities are understaffed, with the local average being 43% staffed (so less than ½ of what international standards would suggest was necessary). So if someone goes away to be trained, his or her job is either shared among already overworked staff – or not done at all if no one else has those skills. It results in an increased potential for deaths at the facility, the longer a staff member is away.

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In addition, the dispensaries (the first level of health facility) are only set up to do certain basic things – if a more complex case arrives, the patient is referred to the nearest Health Centre or hospital… which could be hours away, or totally inaccessible in the rainy season. So, dispensary midwives must be able to deal with the emergencies that occur most frequently, or else stabilize the patient for referral to a larger health centre. With many maternity issues, if it is not treated immediately, referral will be too late – for the mother, newborn or both.

Over 60% of maternal deaths in Tanzania are caused by 5 factors – post-delivery bleeding (haemorrhage), pre-eclampsia or eclampsia, obstructed labour, sepsis (blood poisoning) and anaemia. Being able to treat these at a community or dispensary level could lower the mortality rate. (Other factors are HIV/AIDS status, malaria and obstructed labour.) So training midwives to treat these key factors makes sense.

 

Another factor is learning practical skills: research shows that low dose, high frequency training is better retained than extensive, lengthy and intensive training. Teaching a midwife a skill, then having her repeat it in her workplace, helps her retain the knowledge. While in-workplace training would be ideal, it is neither efficient nor cost-effective in Tanzania. So, following the shorter training, TAMA uses experienced mentors to follow up in the workplace.

So, while, as donors, we may wish to provide “only the best” emergency skills training for the recipients, we should not assume “the best” would be what we would want or expect in Canada. We must take into account the realities of the medical system in the receiving country, address the most common emergencies, and ensure the practical skill is taught in a way to maximize retention of knowledge.

 

Time Flies When You’re Having Fun…at work

In a week, I will have been here for 4 months – hard for me to believe! It seems like we are just getting started.  Just 5 more months to to work on a problem that keeps developing more layers – rather like an onion, except crying is not a direct consequence… just indirect – for those the current system has failed.

It’s time to tell you more about the Tanzania Midwives Association (TAMA), where I am working. It is a registered, professional organization run by extremely dedicated volunteers and a small number of project-funded staff. Its (new) Vision and Mission are:

VISION:

Every childbearing woman, newborn and child has access to quality care from a competent midwife.

MISSION:

Advancing midwifery by promoting independent, skilled midwives as the main caregivers for childbearing mothers, newborns & children, in a coordinated healthcare system.

Photo credit: Johnson & Johnson

The UN‘s 2030 Agenda for Sustainable Development (aka SDGs) includes a Declaration to end all preventable newborn, child and maternal mortality. Tanzania has committed to work toward this goal, but it is just one among many priorities in an underfunded, understaffed and struggling health care system. Should money go towards preventative services, including competent midwifery care, or go to build more operating rooms for emergency or reactive care? How should these choices be balanced? This dilemma is being debated in every country – but it is even harder when the funds are so limited.

TAMA has about 4000 members, who are all trained in both nursing and midwifery. This may sound good, but it creates a real problem. Students are trained to do ordinary deliveries, not how to deal with emergencies that occur during pregnancy and delivery. Only 1/4 to 1/3  of the already limited curriculum is spent on midwifery specific topics – so, students graduate without knowing many of the standard international midwifery competencies.   While the curriculum is being revised, a gap still exists.  So TAMA has stepped in, with funding from a number of NGOs (including CUSO), plus additional expertise from the Canadian Association of Midwives, to train midwives in emergency maternity issues and newborn resuscitation procedures.

However, once placed,  they can be rotated between nursing and midwifery positions. This means that midwives who receive upgrading may not remain in a post where the newly learned skills can be used…and may lose them from lack of application. One suggestion is to have the applicable Medical Officer commit to keeping midwives who have received the upgraded Midwives Emergency Skills Training (MEST) in midwifery positions for an agreed period of time. The issue of availability of staff would have to be factored in.

These issues need to be addressed urgently. Tanzania has one of the highest maternal death rates in the world: 576 per 100,000 deliveries. With current population and delivery rates, this is about 8000 deaths annually – and that is just the mothers. Compare this to Sweden, which boasts a 3/100,000 rate. Canada’s is 7/100,000. So many deaths here are preventable.

Contributing factors include: poverty, a largely rural population, lack of knowledge about issues that can arise during pregnancy, the father’s prerogative to decide if a woman can even seek care, plus limited health services. Abortion is illegal here, but, as everywhere, still occurs – and some women may be afraid (or not allowed) to go to a health centre if complications arise.  In a recent survey, very few participants in Shinyanga or Simiyu could identify 3 or more of the danger signs listed below – yet knowing them could save a pregnant woman’s life. Midwives could provide this information during ante-natal visits, so that women and their partners could go to health centres as soon as an issue occurred. The sooner treatment starts, the more likely a mother and her unborn child will survive.

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Another issue is that TAMA’s funding is project-based. Projects are restricted to specific geographic areas and set topics (e.g. teaching emergency procedures, family planning, respectful care). The coordination or sharing between projects funded by different NGOs is not automatic, so once a project is finished, data, learnings – plus well-trained staff – may be lost. This is an ongoing problem with project-based work anywhere. So the need to capture and carry ideas forward to subsequent projects can fall off the table unless specific goals are identified, built into the project plan and funded. The Tanzania  government also needs to be part of the up-front commitments, so that midwives who have been trained are retained when a project ends. We plan to do a cost/benefit analysis to support moving towards more preventative maternal care, including a specific midwifery cadre. (Any post-grads out there looking for a thesis topic???)

Another of TAMA’s goals is to coordinate its data, so that each of its projects can build upon the information from previous projects, and the data can be shared with its partners. It is working with other NGOs (non-governmental organizations) to identify common goals, overlapping projects and opportunities for collaborating. I just returned from Shinyanga, a Region in the Lake Zone (near Lake Victoria) where we spent several days discussing this. This new initiative should help with advocacy – both internally in Tanzania and externally with international partners.

Photos: En route to Shinyanga, via Mwanza on Lake Victoria, aka Rock City.

And when I am not traveling? I redrafted TAMA’s 1992 Constitution, interpret legislation, work with TAMA’s Executive to create a new strategic plan, identify which objectives are critical, operational, strategic or tactical, (eyes glazing over yet?), am preparing an advocacy plan and generally try to help when a skills gap is identified. Luckily I have worked in enough roles that I can look up a precedent or know whom to ask. And the people I am working with are very knowledgeable and good to collaborate with. It works well (as long as the power is on!). Time is flying by.

Mud, mud, glorious mud, Nothing quite like it for cooling the blood….*

It is interesting how our bodies adjust to new-to-us temperatures, if we let them. It is regularly 30+C  here, hotter in the sun. Clearly avoiding mid-day excursions (siestas anyone?) is recommended. But life must go on.8029D8C6-285E-4511-A41A-2BEF03721285Many people here do not have air conditioning, or choose not to have it because of the extremely high electrical costs. When it drops down to 25 – 26C, I have seen babies swaddled in blankets or with wool caps, men wearing light down vests and women wearing sweaters or wraps, because “it is cold”.

When we first arrived, our A/C ran daily. Gradually, as we learned to open windows in the early a.m. and in the evening, creating a cross-breeze through the apartment, it was used less and less. Our electrical bill was more than halved. We walked more slowly, sought the shade, and drank plenty of water. Our assessment of “how hot it was” changed.

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On safari, we saw how animals adjust. Many are nocturnal and avoid the heat. During the day we saw hyenas, lions and cheetah all resting under in the shade – under large rocks or in bushes. The predominant shrub has prickly barbs, so the older the lion, the less mane it has…but it is a cool cat. No such loss for the leopard, who seeks loftier sites….

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Clearly going into the water is a good idea…as long as it doesn’t hold any of your predators, or you can move faster than they do! So hippos co-exist with crocodiles (but go elsewhere, if possible, when their babies are still vulnerable), and ibis, cranes and heron join them. Elephants dig holes near water so that they get “filtered” water…no bugs or frogs up their trunks, thank you very much! Then the terapin turtle uses the elephant wallow as its home…at least until the sun evaporates the water. Elephants, being large, have several ways to cool off. Their ears have many veins running through them, so when they flap them, it cools the passing blood. Animals’ horns and tusks help regulate heat as well. A nice mud bath is cooling, with the added benefit of keeping insects at bay, as demonstrated by Cape Buffalo, who clearly are annoyed that their day at the spa is being interupted….4059B2A2-739E-42CE-9648-29FAB0910B5D

5582B6D7-4BB4-4535-9B25-29D1F22673DDOthers use the heat to their advantage: eagles and vultures use the thermal currents to help them soar. Early mornings, they are on the tree tops, waiting for the air to heat up so they can fly, as it takes too much energy without the thermal lift. Black headed buffalo weavers (another bird) build their nests, large circular clumps, on the east or west side of trees, so the sun warms the eggs – and the parents get time off.  A bit lower down, dung beetles lay their eggs in various animal scat. When heated by the sun it becomes just the right temperature for the eggs to hatch.

Colours are effective temperature adjusters: the zebras’ black stripes absorb heat for cool nights and the white reflects it away during the day. Male ostrich (black) stay on the nests at night, while the (beige) females nest during the day. (Nice to see equally shared parenting! They also have communal nests of up to 25 eggs – sort of an egg daycare – sharing the work even further.)

Any finally, it’s cool to live underground – even more so if you can get someone else to build your house for you, as Dwarf mongoose do! Monitor lizards lay their eggs in termite mounds so when the little  lizards hatch there is a ready food supply of termites.  Once the food supply is depleted they move out, and the Dwarf mongoose move in to a lovely, cool, underground mansion.

For those people who can afford it, a mansion, with a balcony cooled by the sea breeze might be more ideal, such as the Sultan’s palace (now a museum) in Stone Town.AD6F6322-5FE4-4117-86D4-E1882D12306D

Not having a mansion, nor a mud hole, I make do with a swimming pool – a perfectly fine  way to cool down, until an ocean is available!

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Lions and cheetahs and snakes, oh my!

Daniel and I went to the Mwagusi Safari Camp in Ruaha National Park, Tanzania for 5 amazing and full (very full!) days over Christmas. We saw four of the major five (no rhinos in that park): 11 different lions/lionesses, 1 leopard (eating an impala, then in a tree), herds of elephants and Cape buffalo – collectives of many other African animals – a coalition of cheetahs, herds of  impala, a dazzle of zebra, lesser and greater kudu (an antelope), waterbuck, towering giraffes, a pod (or bloat) of hippos, troops of baboons and monkeys, and a bask of crocodiles.

Smaller animals were more skittish or hidden, but we still saw a mating pair of hyenas, hyrax, dikdik, warthogs, mongoose, fox, jackal, leopard tortoises,  monitor lizards, right down to the mighty dung beetle. Overhead or in trees waiting for the thermal updrafts were flocks of birds – eagles, heron, crane, vultures, rollers, weavers – and on the ground, 2 baby spitting cobra right beside our banda(!) and the lion ant – not to be confused with the lion fly, which is tick-like. While the latter prefers lions, humans will do, as I learned. The list continues, but not here!

Mwagusi camp itself was a delight: the people, the guides (special thanks to Baldon & Isaac!), the food – always with many vegetarian choices, the ambiance, the accommodations – real glamping – (amazing for a place in the middle of the park, with only solar power). The camp can accommodate 30 people, but our maximum was eight. Seventeen were to arrive the day after we left. The Christmas celebrations were very special, interrupted by a leopard sighting!

Days started at 6 a.m. for a 5 hour game drive (picnic breakfasts) in a comfortable, open sided Jeep (which makes for amazing views but is not for the faint of heart – although apparently the animals think we are part of the Jeep so didn’t treat us as a threat, or as a treat…), lunch, rest hour (just like summer camp), afternoon game drive, shower, dinner, bed and repeat.  So after 5 days it was time for some R&R – so we flew to Zanzibar for a New Year’s beach holiday in Nungwi. One day was spent with friends in Stone Town, but otherwise it was snorkelling, (Daniel did his 20th and 21st scuba dives), long beach walks and hammock time. Daniel went to Kendwa (Rocks!) for New Years. I passed.  I will return to Stone Town – the powerful slave memorial (Stone Town was the hub of the Indian Ocean slave trade), historical buildings, busy markets and winding alleys. Grist for another blog.DSC00578

I am now back at work in Dar es Salaam and Daniel is in Istanbul, then Athens as he gradually wends his way back to Canada.  Happy New Year!