Midwifery in Tanzania

AIMS Journal, 2014, Vol 26 No 4

Rose Mlay gives a view from the ground

In Tanzania women believe that it is a bad omen to tell other people you are pregnant. Even when pregnancy can be seen, we do not want to discuss it. The ‘expected date of delivery’ (EDD) is not in a Tanzanian woman’s vocabulary.

Instead, we say to each other, ‘ni mja mzito’ (she has become heavy), but no one wants to know when she is going to become light again. Only the midwives want to know, because they have learned how important this is. So why is this, why the hiding? It is simply because women fear they might die. They have seen friends, relatives and other mothers dying in childbirth, and they do not know why a healthy woman should die. We have a saying that ‘a pregnant woman has one foot in the grave,’ so to speak of the impending birth is a bad omen.

This is why I welcome the recent Lancet report, and the slogan of the International Confederation of Midwives that today ‘the World Needs Midwives More Than Ever’. As a midwife, as a mother and as national coordinator of the White Ribbon Alliance in Tanzania, I know the crucial role of midwives in preventing disabilities and deaths related to pregnancy.

As an advocate in Tanzania, I call for action to end the global scandal in which 99% of the world’s maternal deaths occur in developing countries, many of these in sub-Saharan Africa including my own country. It is high time our governments became accountable for these needless deaths. We are urging them to invest in women and midwifery, just as more developed countries have done over many decades. For example, while developed countries such as Sweden have a maternal death rate of less than 4 per 100,000 live births, Tanzania has 454 maternal deaths per 100,000 live births. Why? Sweden has 11.9 nursemidwives for every 1000 people compared to Tanzania which has 0.2 nurse-midwives for every 1000 people.^{1, 2}

Midwives have a crucial role in reducing maternal and newborn deaths. AIMS readers will know that obstructed labour and ruptured uterus are highly dangerous, and globally they contribute to 70% of all maternal deaths. Ditto, high blood pressure leading to eclampsia, severe bleeding before and after pregnancy, infection, fetal distress and asphyxia are all potentially lethal – especially in countries where up to half of women givebirth alone at home or with only a neighbour or relative to help. In developed countries, an ambulance is often on hand to assist a birthing woman if needed. In my country, a woman may face a two-day walk to reach the nearest hospital – yet she can die of bleeding within two hours.

The way to prevent these deaths is to invest in the professional midwives who will be the first to recognise when a woman or her newborn are at risk from complications. This is the path that Sweden followed when it took responsibility for safe birth by being accountable to its citizens and investing in midwives. Sweden, as a result, dramatically reduced its maternal deaths from 900/100,000 in the 18th century to 4/100,000 in 2010.¹

Realising this, the White Ribbon Alliance for Safe Motherhood Tanzania (WRATZ) has been campaigning for our government to increase the numbers of qualified staff as the best strategy to reduce maternal and newborn deaths. In 2006, we protested to our government that Tanzania had many midwives who were either unemployed or doing other work, due to the lack ofsalaried government jobs. They heard our call and decided to lift the employment ban which had been imposed on health staff. As a result of White Ribbon Alliance advocacy, the government changed its policy in order to employ all new midwives so that they went straight to work as soon they graduated from their training.

However, WRATZ then found that the pool of graduatingmidwives was not large enough – and so for the past three years (with funds and other support from the Bill and Melinda Gates Foundation and others, sourced by the WRA Global Secretariat), we started a campaign to boost the career of midwifery. Our theme is ‘be in science; choose midwifery’.As a result, tens of thousands of secondary school youths were
informed of the situation – that in our country, mothers are dying alone or with unskilled personnel during childbirth.

As a result of our campaign, the government built science laboratories in secondary schools and provided loans to university students to become science teachers. Many students subsequently decided to study science and choose midwifery so that they could help to save the lives of women and newborns.

This campaign is ongoing, with White Ribbon Alliance Youth Clubs in 12 secondary schools so that new students are helped to make informed choices. Until recently, too, our joint nursing and midwifery curriculum meant that midwives worked in medical and surgical wards as well as labour wards, gradually losing their midwifery competencies. But now, midwifery degree courses have started in Tanzania so that we have the opportunity to build a truly expert midwifery workforce.

Yet it can still be very demoralising if these students become midwives and/or medical doctors eager to save lives, only to find they cannot do so because of poor health facilities, lack of other trained staff and terrible working conditions.

In order to save women’s and newborns’ lives during childbirth, we must have not only skilled health workers in place, but also Comprehensive Emergency Obstetric and Newborn Care (CEmONC) facilities.

CEmONC includes immediate access by women with complications to the required life-saving medications and services such as blood transfusion and caesarean section. This means there must be a functioning operating theatre available, 24 hours a day, seven days a week.

Our President did promise in 2008 that these services would be available in half of our health facilities. And this is precisely what the WRATZ is now calling for in our campaign ‘wajibika mama aishi’ (be accountable so that mothers and newborns can survive childbirth). We have now won the support of our Prime Minister and many Parliamentarians as well as other government leaders. Citizens of Tanzania – through petitions, public meetings and media appearances – are now calling for a specific budget line for CEmONC, to make sure that 50% of health centres in Tanzania can provide CEmONC by 2015, as was originally promised.

When we began in 2013, White Ribbon Alliance members in the rural area of Rukwa surveyed their own health facilities and found that, in this region of a million people, there was not one health facility providing CEmONC. Since we have made that widely known, involving politicians and the media, we have seen rapid changes.

The results of our recent monitoring and evaluation of this campaign in Rukwa show that all the Comprehensive Council Health Plans (CCHPs) of the four districts of Rukwa now have a budget line item for CEmONC – for the first time in the history of Tanzania. We have not been able to check all districts of Tanzania, but we believe it is likely – given the national directive issued by the Prime Minister – that they all now have this budget line item.

The most recent and exciting part of our story, is that in our latest meeting on 27 August 2014 (which included the top leadership and implementers of all four districts of Rukwa), it became clear that because of the White Ribbon Alliance campaign, five out of the ten government health centres will provide CEmONC by 2015.

And so it appears likely that by the time our students choose midwifery, they will be able to fulfil their roles as midwives and be happy to save lives of mothers and newborn babies during childbirth!

I want to thank all those – globally and nationally – who have joined our efforts to support the pregnant women of Tanzania so that both their feet are on the ground, and so that they and their newborn can survive childbirth.

We all have to ‘wajibika mama aishi’ (be accountable so that mothers and newborns can survive childbirth). People from all walks of life are interested in forming a coalition and pulling the pregnant woman’s one foot from the grave and help her stand on two feet and live.

Please see a film about Rukwa and the health facilities here: whiteribbonalliance.org/campaigns/promotion-midwifery/

References
1. World Bank (2013) Annual Report 2013. End extreme poverty. Promote shared prosperity. go.worldbank.org/OB1TP4KXM0
2. National Bureau of Statistics Dar es Salaam, Tanzania (2011) Tanzania Demographic and Health Survey 2010. ICF Macro Calverton, Maryland, USA