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.