Maternal Health in Zanzibar Baseline Health Assessment

Maternal  Health  in  Zanzibar:  Baseline  Health  Assessment   Introduction   Maternal  mortality  is,  in  most  cases,  preventable.  For  this  reason,  99%  of  maternal   mortality  cases  occur  in  developing  countries,  where  there  are  high  rates  of  home   births  and  hospitals  lack  for  resources  and  wellz trained  staff.  In  a  collaborative   effort,  students  from  The  State  University  of  Zanzibar’s  (SUZA)  School  of  Medicine   and  Boston  University’s  department  of  Biomedical  Engineering  completed  a   baseline  health  assessment  of  the  current  state  of  maternal  care  in  Ungunja,   Zanzibar,  Tanzania.     Maternal  mortality  rates  have  seen  an  overall  decrease  in  Zanzibar  in  the  past   several  years,  but  the  current  rate  –  287  per  100,000  deaths  –  is  unacceptable,  and   maternal  mortality  rates  in  mainland  Tanzania  remain  staggeringly  high.  This   assessment  marks  the  beginning  of  the  Global  Health  Technologies  program  in   Zanzibar.  Over  the  next  few  years,  students  from  SUZA  and  BU  will  gain  a  valuable   understanding  of  the  current  maternal  health  system,  and  eventually  improve  it  by   developing  a  device  that  will  suit  the  maternal  health  community  in  Zanzibar.     Methodology   This  project  began  in  Boston  two  months  before  the  BU  students’  arrival  in   Zanzibar.  The  engineering  students  conducted  a  review  of  the  most  common   challenges  facing  maternal  health  in  developing  countries,  particularly  anemia,   postpartum  hemorrhage,  and  prez eclampsia.  In  addition,  they  became  familiar   with  some  of  the  existing  methods  for  diagnosis  and  treatment  of  these  ailments.     The  five  weeks  of  work  in  Zanzibar  involved  a  systematic  process  of  interviewing   mothers,  doctors,  nurses,  midwives,  traditional  birth  attendants  (TBAs)  and   laboratory  technicians.  Each  of  the  three  Boston  University  engineering  students   was  paired  with  one  of  the  three  SUZA  secondz year  medical  students  with  whom   they  would  conduct  the  interviews.   Mothers   While  interviewing  the  pregnant  or  recently  delivered  mothers,  the  teams  inquired   about  the  frequency  and  quality  of  the  mother’s  antenatal  care  visits.  Any   complications  that  had  occurred  during  the  pregnancy  or  delivery  were  noted,  as   was  the  treatment  of  these  complications.  The  mothers  were  asked  whether  they   had  any  difficulty  receiving  care  throughout  their  pregnancy,  such  as  issues  with   transportation  to  the  hospital.  They  were  also  asked  why  they  chose  to  deliver   where  they  did  or  would  –  either  at  the  hospital  or  at  home.     Hospital  Health  Staff   The  health  workers  in  the  hospitals  –  doctors,  nurses,  and  midwives  –  were  all   asked  the  same  questions.  What  is  the  biggest  barrier  to  maternal  care?  What  do   you  see  as  the  leading  cause  of  poor  maternal  health  and  maternal  mortality?  How  is   that  particular  condition  treated  in  this  hospital,  and  how  could  the  treatment  be   improved?  These  questions  were  meant  to  determine  the  biggest  gap  in  the  current   course  of  treatment.   Laboratory  Staff   The  lab  technicians  were  asked  what  testing  takes  place  at  their  facility,  what   equipment  is  used  for  it,  and  what  the  cost  is  for  the  patient.  Energy  constraints  for   devices  were  also  noted.     Traditional  Birth  Attendants  (TBAs)   The  TBAs  were  asked  how  much  training  they  had  received  and  how  many  years  of   experience  they  had.  The  frequency  of  their  work  (how  many  mothers  assisted  per   month)  was  noted.  They  were  asked  what  tools  they  used  and  who  provided  these   tools.  Lastly,  they  were  asked  why  they  thought  women  deliver  at  home  instead  of   seeking  care  at  a  hospital.     Results   In  total,  over  150  mothers  and  55  health  workers  were  interviewed.  Seven  hospitals   were  visited  including  Mnazi  Mmoja  Hospital  (MMH),  Mwembeladu,  Fuoni,   Bumbwini,  Rahaleo,  Kivunge,  and  Makunduchi.   Mothers   Mild  to  severe  anemia  occurred  in  roughly  one  fourth  of  the  women.  Use  of   traditional  medicine  was  common,  often  as  a  supplement  to  hospital  supplied   medicine.  For  anemia  treatment,  women  were  usually  given  a  one-­‐month  supply  of   pills  and  advised  to  change  their  diet.  When  a  hospital  was  experiencing  shortages   of  pills,  mothers  would  only  be  advised  a  diet  change.  Most  women  had  experienced   complications  during  at  least  one  of  their  pregnancies.  MMH  had,  overwhelmingly,   the  highest  rates  of  maternal  mortality  and  neonatal  mortality.  This  was  given  by   their  statistics  board,  and  also  by  the  interviews  conducted  there.  The  six  MMH   mothers  interviewed  in  the  post-­‐natal  ward  all  had  severe  complications:  two  cases   of  PPH,  one  of  which  led  to  blood  transfusion  and  neonatal  mortality,  two  C-­‐Section   deliveries,  and  five  cases  of  mild  to  severe  anemia.   2   When  asked  if  they  had  any  difficulties  accessing  or  receiving  care,  almost  100%   said  no.  Interestingly,  when  asked  specifically  about  transportation,  some  conceded   they  had  to  walk  upwards  of  two  hours  to  reach  the  hospital.  In  some  centers,   particularly  at  Bumbwini  hospital,  there  was  a  financial  barrier  to  receiving   ultrasound  testing,  which  can  cost  anywhere  from  7,000  to  10,000  TSH.  Some   mothers  stated  they  were  not  advised  to  get  an  ultrasound  by  their  doctor,  so  they   did  not  think  to  get  one.  Overall,  women  seemed  to  believe  it  was  much  safer  to   deliver  at  a  hospital  than  at  home.  There  was  a  general  confidence  in  the  hospital   staff’s  ability  to  handle  any  complications  that  might  arise  during  childbirth.  This   mindset  came  from  both  health  education  at  the  hospital  and  encouragement  from   their  local  community.     Transportation  was  often  a  barrier  to  women  receiving  quality  care  during  their   delivery.  Though  women  understood  the  importance  of  giving  birth  at  a  hospital   where  trained  medical  professionals  can  handle  any  severe  complications  that  may   arise,  they’re  unable  to  reach  a  hospital  once  they  begin  labor.  While  many  of  the   women  spoken  to  had  given  birth  at  home  for  at  least  one  of  her  pregnancies,  this   was  usually  due  to  sudden  delivery  that  rendered  her  unable  to  reach  a  hospital  in   time.  They  often  stated  that,  had  they  had  the  time  or  money  for  transport,  they   would  have  preferred  to  deliver  the  child  at  the  hospital.     Those  women  who  delivered  at  home  purposefully  –  not  because  of  lack  of   transport  to  a  hospital  –  usually  did  so  because  of  privacy  and  cultural  beliefs.   Additionally,  mothers  who  were  forced  deliver  a  child  at  home  because  of  lack  of   transportation  who  experienced  no  complications  would  gain  confidence  in  giving   birth  at  home  and  elect  to  do  so  for  any  later  children  they  had.     Hospital  Health  Staff   The  general  comments  from  doctors,  nurses,  and  midwives  at  the  hospitals  were   that  there  is  a  shortage  of  the  supplies,  staff,  and  space  needed  to  provide  patients   with  true  quality  care.  Some  facilities  had  only  one  ambulance,  and  some  had  no   working  ambulances.  Many  facilities  did  not  have  an  ultrasound  machine,  and  would   receive  a  device  from  Mnazi  Mmoja  Hospital  once  or  twice  a  month  to  assist   pregnant  mothers.  Equipment  used  to  aid  mothers  and  infants  was  often  broken,   such  as  vacuums  to  realign  a  baby’s  spine  during  delivery  and  machines  to  clear  a   newborn  infant’s  airway  of  mucus.  Many  hospitals  also  said  there  was  a  shortage  of   functional  blood  pressure  machines,  and  frequent  shortages  of  various  kinds  of  pills   such  as  those  to  treat  anemia  and  high  blood  pressure.   Post-­‐partum  hemorrhage  was  treated  with  misoprostol  in  the  maternal  wards  at   Mnazi  Mmoja  and  Kivunge,  and  oxytocin  at  Makunduchi,  Bumbwini,  Mwembeladu.   Severe  cases  where  a  mother  would  need  a  blood  transfusion  were  then  transferred   to  Mnazi  Mmoja.   3   Laboratory  Technicians   Laboratory  testing  for  antenatal  care  included  an  HIV  test,  malaria  test,  hemoglobin   test,  and  urine  test  to  check  for  protein  and  glucose  levels.  Hemocue  was  used  for   anemia  diagnosis  at  all  of  the  visited  hospitals.  Technicians  said  they  occasionally   have  shortages  of  both  the  reagents  and  micro-­‐cuvettes  needed  to  use  the  device,   which  are  the  two  main  cost  contributors.  The  cost  to  test  for  hemoglobin  levels   varied  from  facility  to  facility,  and  fell  between  1,000  and  2,000  TSH  (0.50  and  1   USD).  Hemocue  uses  electricity,  but  has  battery  backup.  Fuoni  hospital  used  a  paper   hemoglobin  test  in  their  maternity  ward,  which  the  staff  found  inaccurate  and   unreliable.  Hemocue  was  used  in  Fuoni’s  general  ward,  and  though  staff  said  it  was   more  accurate  than  paper  tests,  the  model  they  had  was  outdated.  Urinalysis  for   pre-­‐eclampsia  diagnosis  was  done  with  paper  dip  testing  at  all  facilities.     Traditional  Birth  Attendants   The  eight  TBAs  spoken  to  had  received  a  wide  range  of  training,  from  no  formal   midwifery  education  to  extensive  training  on  mainland  Tanzania.  The  equipment   the  TBAs  used  were  consistent:  gloves,  a  sterilized  blade,  and  thread.  These  supplies   were  given  by  either  the  hospital,  the  TBA  herself,  or  by  the  pregnant  mother.  Some   TBAs  noted  that  when  they  were  lacking  any  of  the  supplies  they  would  use   household  items  to  substitute,  such  as  a  plastic  bag  used  as  gloves  or  a  ripped  piece   of  cloth  used  as  thread.  Kangas,  a  common  African  garment  usually  worn  as  a   headscarf  or  skirt,  are  sometimes  used  to  clean  fluids  out  of  a  baby’s  mouth  or  to   stop  excessive  bleeding  in  delivering  mothers  by  applying  pressure.     All  TBAs  stated  they  encourage  women  to  deliver  in  the  hospital  instead  of  at  home.   Most  of  the  cases  they  handled  were  for  those  mothers  who  refused  to  go  to  a   hospital  for  delivery  or  mothers  who  were  delivering  suddenly  and  could  not  get  to   a  hospital  in  time.  Though  the  TBAs  generally  had  10  to  20  years  of  experience,  most   said  they  had  never  experienced  one  or  two  complications  while  assisting  in   delivery.  The  TBAs  noted  that  the  number  of  home  births  had  decreased  drastically   in  the  past  several  years,  and  they  usually  assisted  in  less  than  five  births  each   month.   Discussion   The  ineffective  referral  system  in  Ungunja  is  the  main  cause  of  MMH’s  excessive   burden.  Because  all  complicated  cases  are  delegated  to  MMH,  which  is  the  only   referral  hospital  on  the  island,  its  maternity  ward  handles  50%  of  Ungunja  births.  A   mother’s  first  child  is  considered  a  complicated  case,  as  are  any  children  after  her   fourth,  so  all  of  these  are  referred  to  MMH.  Any  pregnancies  that  will  require  a  C-­‐ Section  delivery  are  referred  to  MMH.  Mothers  diagnosed  with  pre-­‐eclampsia  are   referred  to  MMH.  Women  suffering  from  severe  PPH  are  transferred  to  MMH.  And   oftentimes  women  are  referred  too  late,  so  they  or  their  infant  dies  of  severe  shock   while  being  transported  to  receive  better  care.  These  deaths  contribute  to  MMH’s   maternal  and  neonatal  mortality  statistics,  which  explains  the  high  numbers  that   4   occur  there.  In  order  to  decrease  the  burden  on  MMH,  it  is  imperative  that  the   quality  of  care  in  regional  hospitals  improves.   The  leading  gynecologist  at  MMH  gave  valuable  feedback  about  what  equipment   they  lack.  Particularly,  he  pointed  out  that  they  do  not  have  any  available  testing  for   renal  and  liver  function.  Poor  function  of  the  liver  and  kidneys  can  cause  a  host  of   problems  both  in  maternal  health  and  otherwise,  so  the  development  of  an   affordable  bedside  test  would  be  incredibly  valuable.  A  more  cost  effective  point-­‐of-­‐ care  hemoglobin  test  would  also  be  of  great  use.  All  of  the  hospitals  we  visited  use  a   Hemocue  device.  Though  it  is  relatively  affordable,  it  could  still  be  made  cheaper   without  the  use  of  micro-­‐cuvettes  and  perhaps  different  reagents.  Decreasing  the   cost  of  the  blood  level  test  to  less  than  1,000  TSH  (0.50  USD)  would  encourage  more   women  to  come.  A  non-­‐invasive  method  of  hemoglobin  testing  might  increase  the   frequency  of  testing  for  patients,  as  it  could  be  made  extremely  cost  effective  and   would  remove  the  discomfort  of  drawing  blood.     Anemia  is  treated  with  the  prescription  of  supplement  pills.  These  pills  are  free   when  given  by  the  hospital,  but  hospitals  experience  shortages  of  them.  They  are   given  a  supply  meant  to  last  three  months  that  sometimes  only  lasts  one.  This  is   most  likely  due  to  patients  flocking  to  better-­‐stocked  hospitals  and  depleting  their   supplies  quickly.  Though  a  hospital  is  given  a  three-­‐month  supply  based  on  the   surrounding  population,  it  is  not  enough  to  suit  the  number  of  patients  they  actually   receive.  Improved  distribution  of  resources  to  smaller  health  facilities  –  if  there  are   any  -­‐  might  increase  local  confidence  and  reduce  the  burden  on  the  larger  hospitals.   An  exploration  of  dispensaries  and  small  community  clinics  is  necessary  to   determine  the  true  cause  of  the  frequent  shortages.     Though  the  collected  information  shows  many  women  do  come  to  at  least  four   antenatal  care  visits,  doctors  stated  the  number  who  come  are  not  representative  of   the  maternal  population  at  large  and  it  is  common  for  women  to  begin  her  antenatal   visits  too  late.  The  data  of  this  field  study  is  limited  by  the  fact  that  only  mothers  at   hospitals  were  interviewed.  Thus,  the  study  was  only  able  to  reach  women  who  are   aware  of  the  benefits  of  antenatal  care.  Smaller  community  health  clinics  were  not   visited,  so  mothers  who  do  not  seek  antenatal  care  frequently  or  at  all  may  be   neglected  from  the  current  data  set.  These  people  might  benefit  the  most  from  a   very  simple  device  that  could  mean  the  difference  between  life  and  death  in  an   emergency  situation,  or  at  the  very  least  a  health  education  program.  One  potential   solution  is  a  public  service  announcement  to  increase  awareness  of  the  benefits  of   attending  antenatal  care  visits,  such  as  a  text  blast  in  cooperation  with  one  of  the   local  phone  companies.     The  next  phase  of  research  should  involve  reaching  these  women  and  health   workers  by  conducting  interviews  in  more  remote  communities.  It  is  important  that   these  mothers  and  the  traditional  birth  attendants  or  clinicians  who  attend  them  are   recognized  in  this  process  to  gain  an  honest  understanding  of  the  maternal  health   community.     5