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!

 

 

 

 

 

 

 

 

 

 

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.