Make Motherhood Safe for Tanzanian Women

by Kupona Foundation
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Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
Make Motherhood Safe for Tanzanian Women
The new maternity hospital, taken 31 Dec 2012
The new maternity hospital, taken 31 Dec 2012

Some of you have heard the story of Beatrice, who received surgery at our hospital in Dar es Salaam for fistula, completed a one-year training course in craft and business skills at our Mabinti Center, and in May, safely gave birth to a healthy baby boy. In 2012, CCBRT treated more than 500 women like Beatrice, repairing their fistulas and giving them true second chances to live their dreams.

 

Kupona Foundation and our implementing partner CCBRT have been working together since 2009 to transform and improve maternal health care in Tanzania - to prevent fistula and ensure that joy and safety during pregnancy and childbirth is possible for ALL Tanzanian women.  Our capacity building initiatives have helped to improve care at 16 existing health facilities in the Dar es Salaam region and highlighted CCBRT as a leader in the area of maternal health.  But in 2012, our vision began to take concrete shape with the construction of the new CCBRT Maternity and Newborn Hospital.  All funds for the construction and equipping of the new hospital have been committed and progress has been incredible since breaking ground in December 2011.  In fact, the kitchen and canteen facilities will be ready for use in the first part of this year, and three of the building blocks have been constructed up to roof level. Twice in 2012, His Excellency President Kikwete of Tanzania visited the progressing site of the new hospital, and we continue to be motivated by this high-level support.

 

Here in the United States, Kupona's mission to expand private support for CCBRT also reached new heights, with our final tally in 2012 reaching over $219,000 - more than two times our total in 2011!  And every dollar will be used on the ground in Tanzania to save the lives of mothers and babies. 

 

We know that, even as our physical facility takes shape, the pressure mounts: we must recruit qualified staff, improve of the regional referral system to prevent overcrowding at the new hospital, and secure funding for recurring operational expenses.  In 2012, we worked closely with some fantastic partners to develop a human resources strategy, an assessment of the current referral system, and an evaluation of family planning services in the region. This year will be one of translating valuable information into action and leveraging the gifts of all of our supporters for maximum impact in the lives of Tanzanian mothers and babies.  We cannot thank you enough for helping us to come this far, and cannot wait to share with you all that 2013 will bring!



Beatrice and Pelis
Beatrice and Pelis

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Construction is in full swing in Dar es Salaam!
Construction is in full swing in Dar es Salaam!

The creation of a new, regional level maternity hospital is a cornerstone of our initiative to reduce maternal and newborn mortality and disability in Tanzania.  To date, we've received funding for four building blocks, and nearly half of the funding for two additional building blocks (a funding gap of $3.3 million remains).  Four buildings will allow our implementing partner, CCBRT, to address the region's most urgent gaps in maternal and newborn health care by providing emergency obstetric care services for high-risk pregnancies, as well as neonatal care for newborns with complications. These four blocks will have a maximum capacity to treat up to 12,000 referrals (including 5,600 cesarean sections), 3,600 newborns with complications and 8,400 healthy newborns. 

Enabling works began in December 2011 for the new hospital, and foundations for all six building blocks have been laid in the hope that sufficient funding can be secured to construct all six blocks, allowing for an increased number of delivery suites, obstetric beds, and neonatal cots, as well as the ability to offer preventative care, health education and family planning services, and early identification of at-risk mothers.

With construction in full swing, we are focusing our efforts NOW on securing sufficient qualified staff to run the new hospital. CCBRT is working with a consultant to develop a comprehensive human resource strategy and effective recruitment procedures, including identifying training schools and offering scholarships to boost the numbers of graduates. The shortage of medical staff in the country is a real challenge, but we remain committed to building up the required skills locally, through our current ongoing trainings at regional facilities, the planned in-service training center at the new maternity hospital, and a developing Consortium project through which members of a group of university-affiliated medical centers in the U.S. will share their experience and expertise with Tanzanians through mentoring, supervision, simulation training and surgical skills.  The Consortium’s program will implement evidence-based comprehensive emergency obstetrical care (CEmOC) protocols and patient safety programs, with the goal of saving lives now and providing the next generation of Tanzanian medical practitioners the education to save lives in the future.

The emphasis on developing skills locally is just one reason why we are thrilled to announce that Dr. Yoni Barnhard has joined the Kupona Foundation Board of Directors as our new President.  Many of you will remember Dr. Barnhard's powerful stories from past GlobalGiving project reports (his "A Slice of Dar" can be found in three parts here). Under his leadership, we know that we will grow Kupona's financial support for CCBRT's work in Tanzania, and bring the vision of the Consortium to fruition - making a substatial and sustainable impact on the lives of women and children.

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This month we are excited to share with you the 2011 Annual Report from our implementer, CCBRT.  Last year was an extremely busy year for us, especially in the area of women's and maternal health.  Our work in fistula broke records and our maternal health program - part of a partnership with the Government of Tanzania - grew drastically and hit major milestones of its own.

The full annual report is included with this update, and contains information on the full scope of initiatives that CCBRT is leading to improve health care for all Tanzanians.  As supporters of our "Make Motherhood Safe for Tanzanian Women" project, you will be particularly interested in these major achievements:

  • Our capacity development program expanded from working with nine government health facilities to sixteen health facilities total.
  • A total of 69 midwives and Assistant Medical Officers (AMOs) attended Basic Emergency Obstetric and Neonatal Care training courses, helping to bring our partner facilities to operate at almost full capacity.
  • We offered short course trainings and continuing medical education courses in specific areas such as infection prevention and control, anesthesia, neonatal care, and the prevention and early detection of disabilities.  These courses provided skills updates, orientations, coaching and mentoring for hundreds of clinical professionals in the Dar es Salaam region.  (Please see page 22 in the annual report for a full listing of trainings and the numbers attending.)

Capacity building activities have continued at full speed in the first half of 2012, with new physical renovations underway at our partner sites, a family planning assessment being conducted in partnership with Engender Health, and additional trainings and educational opportunities being offered throughout the Dar es Salaam region. Paired with the construction of our new maternal health facility, which itself broke ground in December 2011, these capacity development initiatives are critical to building the health infrastructure in Dar es Salaam and making pregnancy and child birth a time of joy, rather than fear. 

Thank you for supporting our work during this exciting time!

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This month, we bring you the third and final story written by Dr. Yoni Barnhard during his time at our programs in Tanzania.  This story that captures the immense hope of second chances: after receiving corrective surgery for an obstetric fistula, AK is able to deliver a healthy baby boy.  It also demonstrates why it is so critical to go beyond treatments such as fistula surgeries to prevention through improved maternal health care.

 

Final Day: Forgiveness

AK is 23 years old.  Aged and experienced in ways a young woman should not understand.  It is not her story as such that is most deeply painful. Rather an avoidable suffering that degrades too many. 

Happy to be pregnant, AK regularly attended her prenatal appointments with the encouragement of her husband.  Unlike many women in sub-Saharan Africa she had access to healthcare.  She understood the symptoms of labor.  And the warning signs of potential complications.

After nearly two full days of regular, searing contractions and two attempts at being admitted to a hospital, AK returned to the hospital in pain, sure that something was wrong. No fetal heart tones could be heard.  Another doctor was called.  He could only confirm an intrauterine fetal death.  Stillbirth.

Labor was induced.  14 hours of agony.  No medication to relieve the pain. She never saw her child.  Four hours later she was sent home.

AK was unable to leave her home for weeks.  Fearful that others would mark her as the cause of a tragedy she had done everything in her power to avoid.

Over the next several weeks, AK noticed a constant sense of wetness between her legs.  The death of her child sprouting uncontrollable nightmares.  She was never given any explanation. AK assumed she had done something wrong. An older neighbor told her she was drinking too much water.  AK stopped drinking water.  The leaking continued.  Another neighbor convinced her this happens to women who are promiscuous.  She had never known any man except her husband. Yet accepted responsibility for her fate.

About a month later AK noticed an advertisement for women with vesico-vaginal fistula.  She mustered the courage to inquire.  After an initial appointment with a health worker, AK was referred to CCBRT, an amazing rehabilitation hospital in Dar that does miraculous work including treatment for women with fistula.  After seeing a doctor at CCBRT, AK was properly evaluated and her underlying condition clearly explained.  It had nothing to do with water.  And certainly was not the result of some imagined past sin.

A compassionate team guided AK and her supportive husband through the process of healing and repair.

The fistula was likely caused by prolonged labor. AK had a hole in her bladder leaking urine into her vagina repaired early one Tuesday morning.   After a week of recovery in the hospital she returned home.  Whole in a certain way for the first time in many months.

AK even took a new job.  Her afternoons were spent counseling other women with fistula at CCBRT.  She spoke with conviction about the possibilities of healing.  From the inside out.  Physically.  Psychologically.  She worked with women in the hope that their husbands’ would not abandon them as is too often the custom for women with fistula. Outcasts.  Placed in an eternal isolation. She gave these other women hope that life could be different.  She praised their initiative.  She honored their taking control of their own lives.  She dignified their every effort.

Seven months later AK missed her first period.  She immediately saw a doctor.  An early pregnancy was confirmed.  An uneventful pregnancy unfolded until late one night around 28 weeks’ gestation.  A little blood.  Some abdominal pain.  Rhythmic tightening just above her pelvic bone. 

AK contacted an amazing doctor at CCBRT.  Doctor Brenda met her late one night at the national hospital, Muhimbili.  She was admitted.  Worked-up.  Medications given to stop her contractions.  Every doctor at Muhimbili knew her history.  A story of loss.  A story of repair.

Days passed.  The contractions waned.  The bleeding subsided.  AK went home to rest.  She lay in bed.  Reduced her activity.  Kept her prenatal appointments.  And time passed.

At about 35 weeks, AK felt a gush of fluid one morning.  The floor below her feet wet.  She contacted Dr. Brenda.  Plans were made.  Admission to Muhimbili arranged.

On an airless, January morning, AK was brought to the operating theater.  She knew well in advance that delivery would be by Cesarean section.  Every effort made to avoid any trauma to the bladder.  To the vaginal tissue. To the suffering buried deep inside her.

A live male infant was delivered.  Healthy.  Shortly after the surgery, Her newborn son was placed on her chest.  He instinctively found a nipple.  His lips moving like the paws of a cat clawing at play.  AK smiled.  Tears on her cheeks.

Before AK left the hospital Dr Brenda asked her about the past year and a half. She looked up from a chair.  Looked beyond the doctor, beyond her pain and she said something I will always remember.  “I will never forget [what happened].  But I have forgiven.  My husband did not leave me despite the fistula.  I now have a beautiful child.  I am a mother.  My life begins now.” 

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This month, we bring you another story written by Dr. Yoni Barnhard during his time volunteering with our maternal health capacity development program. This particular story highlights the systemic obstacles we face in improving the health care available to women in Dar es Salaam.  Last week's doctor strike in Tanzania further highlighted just how overstretched the system is.  Kupona/CCBRT's programs on the ground are committed to strengthening the comprehensive health system.  Dr. Barnhard rightly points out the overwhelming nature of this task; yet without this approach, no promises can be made to women like Anna. 

 

Another Day: Initiation

Accessibility.  The traffic in Dar begins about 6am.  All roads leading toward the city center are clogged by 8am with the backflow stretching many miles along some paths.  The return trip becomes bumper to bumper starting around 3pm and remains at a near-standstill until early evening.  Like Los Angeles most cars have only one passenger. Starch-white clad police direct the intersections. Fortunately my 15 min trip each day is against traffic.  This little trip each morning and evening does make it clear why accessing health care is so difficult.  Besides the high cost of hiring a taxi or even renting someone to carry you on a bike, it is a long journey even within the city and an exhausting voyage for women coming from the rural communities.

 

We begin morning rounds at 8am.  Our meeting place is outside, under the shade of a Baobab tree.  The purpose today is to review the case of a 29 year-old woman who died early Sunday morning, 6 hours after arriving at the hospital.  Anna was 22 weeks’ pregnant with her 7th child.  She came to Amana complaining of headache, abdominal pain, vaginal bleeding and vomiting. Her blood pressure was 200/110.  Although the admitting assistant medical officer recognized the likelihood of severe preeclampsia, there was no quick acting anti-hypertensive medication available at the hospital. After her first seizure this young healthcare provider went from ward to ward trying to borrow a few doses of this medication from other patients.  And though he started magnesium sulfate to prevent recurrent seizures, she continued convulsing.

 

That evening there were more than 20 women in labor at Amana.  The operating theater packed with cesarean deliveries. At 11pm he was called away from Anna to evaluate a woman in active labor with signs of a uterine rupture.  By the time he returned at 12:30 am, Anna was dead.

 

Under the Baobab tree I was trying to make sense of all this.  Over the past 25 days, 31 women have presented to Amana with severe preeclampsia.  Hypertensive disease is the second leading cause of maternal mortality in Tanzania.  Amana does almost 30,000 deliveries each year.  How is it possible that the few medications needed to treat this disease and prevent death are not available?

 

After rounding on the 8 women in the post-C/S ward and spending an hour organizing the work flow on the labor unit we moved toward the primary focus for the day.  It is known as the “sorting room”.  Unlike a Harry Potter story, there is little magic to behold.  It is overwhelming.  Every minute of every day.

 

The gravest obstacle is the lack of staffing.  The entire healthcare system in Dar was designed for a population of 750,000.  The head count today is about 4.4 million.  And while the number of deliveries at Amana has dramatically risen over the past decade, the staffing levels have not increased to keep pace.  At one point I counted 3 nurses, 41 women in labor.  The frustration and burnout is overwhelming.

 

When we arrived, 32 women were in various stages of “sorting”: Active labor, early labor, special attention or discharge.  It is a dizzying sensation.  All these women in their brightly colored khangas.  Some lying on a mattress.  Some lying together on the same mattress.  Several grasping the walls or floor during contractions.  Some moaning.  The sounds muffled by so many other moans. It is impossible to have any clear idea what to do first.

 

No one speaks to the other though many are lying on the same single mattress.  There is a harrowing blank stare.  This is not a happy experience for them.

 

We triaged about 70 women in labor today.  The “special attention” pile was always twice the size of the normal labor pile.  Severe preeclampisa, undiagnosed twins, prolonged labor measured in days not hours and 3 cases of “impending uterine rupture”. When we left the ward, the sun was beginning to set.  The sole operating theater was occupied with a ruptured ectopic and two women in labor were being given blood while awaiting a vacancy.  Those 3 impending ruptured uteri were awaiting transfer to another hospital.

 

Anna made it to the hospital.  She did not get stuck in traffic.  She was fortunate enough to have a relative with a car.  And she died.  On our watch.  That is the thing about it.  The indigestible portion.  The part that gets stuck in the throat.  This was not a failure of Amana.  And surely not a failure of one individual on-call that evening.  This was a monumental failure of the system.  And we are all part of that global, interconnected system.  So yeah, we failed Anna.

Dr. Yoni Barnhard is OBGYN Department Chairman and Director of Maternal-Child Health at Norwalk Hospital, and Associate Clinical Professor at Yale University School of Medicine.

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Kupona Foundation

Location: Washington, DC - USA
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Twitter: @KuponaFdn
Project Leader:
Susana Oguntoye
Executive Director
Washington, DC - District of Columbia United States
$144,433 raised of $400,000 goal
 
2,048 donations
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