After my previous trip to Tanzania, I wrote a short series on chances and challenges in antenatal care and sonography in northern, rural Tanzania (more on that here, here and here). During my most recent visit, I got the chance to further refine my knowledge of the region’s health care map. Let me take you along on my journey.
In the shadow of the Kilimanjaro
My journey started in Moshi, a pretty green and pleasant town at the feet of the omnipresent and impressive highest mountain in Africa, the Kilimanjaro. In Moshi, KCMC can be found, northern Tanzania’s only academical teaching hospital. It is also a highly important institution in with regard to ultrasound, since they offer the only short course in diagnostic sonography in the region. I had a productive meeting with the course director and, as a board member of the Mount Meru Foundation, arranged the application of three sonography candidates who are part of our sponsorship program.
Sonography’s pivotal role
Sitting in the welcoming shade of a tree, and surrounded by termite holes, I met with a Tanzanian midwife-sonographer who graduated from KCMC’s sonography course last year. Currently, he is working in the Africa Amina Alama Hospital, a former health center north of Arusha that was upgraded to a hospital by an Austrian ngo. We had an interesting exchange of experiences and thoroughly agreed on the pivotal role of sonography in mother and child care. As an example, he showed me a photo of a child that had recently been born with congenital abnormalities. This woman wouldn’t have had a scan at all during pregnancy, if it weren’t for the fact that she presented with a fetus in breech position which indicated one. Unfortunately, diagnostic capacity in late pregnancy is limited so the congenital abnormalities went unnoticed. To us, it highlighted the importance of earlier scans, ideally at least one before 24 weeks, as the WHO suggests.
Next up is TPC Hospital, located amidst the vast sugarcane fields south of Moshi. Here, I met with the hospital manager, the head of their Reproductive Health Care clinic and the nurse-midwife who participates in the Mamabus project. This bus, a cooperation between TPC, the ngo Driving Nurses and the Mount Meru Foundation, provides prenatal check ups and other health services to women in the rural areas of the Lower Moshi Region. I joined the nurse-midwife on two occasions for a day of outreach. On our first day together, we visited two schools where 11- and 12-year-old girls were vaccinated against hpv. Not without a reason, since there is a high prevalence of cervical cancer in East-Africa. In Tanzania, 7300 women are diagnosed with it each year, half of whom in a late stage.
My second outreach was with the Mamabus and took us to a nursing school, where expecting women and new mothers can come to receive care. Unfortunately, none of them came that day, due to some logistical problems in the previous period which had prevented the bus from maintaining a regular schedule. It made me think that an alert service through text messages could be very beneficial. Such services already exist in other countries, and I think they have great potential.
Luckily, our trip hadn’t been in vain. Before arriving at the school, we had picked up some boxes of anti-worm medication and Vitamin A capsules to be administered to the pupils. Vitamin A deficiency in children (and women in the reproductive age) is a common problem in Tanzania, with a one sided diet (too much carbs, not enough vegetables) being one of the main causes. Vitamin A deficiency can lead to a range of problems, including blindness and a higher risk of complications from infectious diseases.
Back in the dispensary, a 31-week-pregnant woman was waiting, whom we gave a prenatal checkup. Thanks to the mobile ultrasound machine I had with me, we could also give her a scan. Both our nurse-midwife and the clinical officer in charge of the dispensary were highly interested and gained their first hands-on ultrasound experience. It made me muse about how incredibly helpful an ultrasound machine and the appropriate training would be to this doctor. He is the only equivalent of a doctor in this dispensary, basically tasked with making all diagnoses and referral decisions by himself. Having ultrasound at hand, would certainly make his life easier and improve care.
Back at TPC the next day, I got a thorough tour of several departments. I was lucky enough to be there on the special day their Reproductive Health Clinic regularly hosts for young expectant women (often still teenagers). This wonderful initiative allows them to meet peers in the same situation and experience mutual support.
The hospital’s records are being kept both electronically and on paper. I noticed how the women were weighed with an old fashioned pair of scales (which work perfectly well, although oddly enough nothing was done when they showed that one woman had gained no weight at all between the 20th and 30th week of her pregnancy). Blood pressure was taken (although a pulse of 99 bpm apparently wasn’t a cause for action either), Leopold’s maneuvers performed, heart sounds checked using a Pinard horn, fundal height taken, and, where necessary, iron and folic acid, anti-worm drugs and a tetanus vaccine were given. Furthermore, rapid hiv and malaria tests were performed. Lab orders for serum tests are sent directly from the electronic patient files. The hospital has no clear pathway of medical indications for obstetric ultrasound scans. Their corporate clients receive at least two free ultrasound scans, and the external clients can get a scan on request or based on medical indication (although there is no list of what constitutes a medical indication).
I accompanied a postterm woman who had been referred to the radiology department for an ultrasound scan. According to her file she was 41 weeks pregnant, but since her due date was calculated based on the first day of the last menstruation, this number wasn’t all that reliable. We made the scan, but measurements weren't really exact since one of the switches didn't function properly. In any case, the measurements were only partly relevant at this stage, since this woman hadn’t received any previous scans with which to compare them. We also scanned a second woman who turned out to be 10 weeks and six days pregnant. TPC’s sole radiographer and I determined the due date and discussed the importance of doing so at this stage of the pregnancy.
Our nurse-midwife gave me a tour of the maternity. All newborns get a mtoto-card, a chart on which their condition will be monitored in the upcoming years. That day, the average birth weight was between 2,5 and 3,5 kg, which is quite good for Tanzanian standards. What did strike me, is that half of the mothers gave birth by cesarean section, often after an indication of fetal distress or pelvic cephalic disproportion (CPD). We agree that the high rate of CPD indications during labour in Tanzania is pretty remarkable and disputable, to say the least.
Waiting in line for sonography services
My next visit took me even more south, not far from the Kenyan border. Arriving at Himo Health Center - OPD, a myriad of patients was waiting. Here, the medical doctor in charge is the only one who can make ultrasound scans. He has one machine available, which unfortunately doesn’t function entirely properly. This, much to his own dismay, prohibits him from measuring important parameters such as the abdominal and head circumference.
Pregnancy related ultrasound scans in rural areas like these are offered for free, and many women come to the center to have one. Both the medical doctor and the head of the Reproductive Health Clinic stressed the need for a second machine and a second person to be trained in sonography, who could then perform all obstetric scans. Having witnessed the medical doctor’s workload first hand, it is not difficult to see how this would make a big difference.
Then I made my way to crowded Arusha, where I met with both the new regional medical doctor and the medical doctor in charge of the Mount Meru Hospital. The latter guided me around their radiology department, where I was happy to see the ultrasound machine our ngo donated, up and running perfectly, much to the satisfaction of their staff members. Unfortunately, their current sonographers are not trained in doing dopplers, even though the machine has this functionality and they would really like to learn it.
Finally, I was off to dusty Karatu, a booming town and safari hub, and also my home away from home. My first meeting there was with the new medical doctor in charge of the Karatu Health Center. In his previous job, he had met two American doula’s of Wombs of the World. I got to know them when I was a volunteer in the FAME Hospital and share a passion for promoting a culture of ‘gentle birth’ in Tanzania with them.
The medical doctor is a highly professional man with clear ambitions to further improve the level of care offered in his center. Our ngo is involved in efforts to implement obstetric sonography her. Since Wombs of the World is currently raising funds to donate an ultrasound machine, the medical doctor and I discussed the process of training staff members to work with the new machine, and how to further implement sonographic services into this center’s setting.
Much to be gained
At the conclusion of our meeting, I was offered a tour of the hospital. At the maternity, I met two of the four Dutch midwifery students with whom I am in touch through Facebook, after which we were off to the surgical theater, the dentist’s room, the injection room, pharmacy and finally the Reproductive Health Clinic. Looking at the huge number of mothers and babies there - many women deliver in this hospital and many come here because of the free prenatal checkups it offers - I wondered if there’s even time to see all of them that same day. The medical doctor in charge was proud to show me the construction work that is currently underway which will allow for expanding and improving the center’s maternity and neonatal services so needed in this rural community. Lots of good work is done there, but there’s also still much to be gained. We agreed that having both doula’s and ultrasound at hand, could do a lot of good.
Finally, I met Leesha, a Canadian midwife who married a Tanzanian and has been living in Tanzania for years now. Besides being a nurse-educator at FAME Hospital, she runs several commercial and charitable projects under the name of Boma Africa. We specifically discussed her plan to open a midwifery led birth center, in which she wants to implement sonography to allow for timely referral of high risk pregnancies. She has asked our ngo to contribute to training a midwife in sonography.
Chances & challenges
Visiting these health care facilities, I noticed a couple of things. Firstly, that the more rural the circumstances get, the more I feel at home in them. The remote areas in which they are located, demand a lot of caregivers’ own good judgement and medical skills, as they are often the only ones there serving a wide variety of people with a wide variety of complaints. They are often pioneers who have to be very allround and make the best of the situation with very limited means. As such, they are very inspiring.
Finally, this closer look into health care facilities in northern Tanzania, reiterated some of the chances and challenges I previously noticed for obstetric sonography in rural areas, and added some insights as well:
Mobile ultrasound technology has the potential to make a great difference in remote areas, where it would be of great help in setting diagnoses and making timely referrals
The great variety of patients and complaints will help caregivers to develop and maintain allround ultrasound skills
Ultrasound scans may be offered for (almost) free in these areas, if equipment and trained staff are available
mHealth services in remote areas may have a great impact on antenatal care through informing mothers and pregnant women and reminding them of consultations and services
Among the possible setbacks I noticed were lack of a good, steady power supply (or the financial means of paying for it), and problems in maintaining equipment (having it serviced properly is often difficult)
From an educational point of view, what I would call ‘integrated teaching’ seems best suited: start from what people already know and can do, work side-by-side with them and from thereon, further sharpen their thinking on what you do, why you do it, what that means, and what the next steps are
Like in other countries, the private health sector pays better than the public system, leading to the public sector losing well trained and experienced personnel and it especially comes at the expense of the expertise in rural areas
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