Source: Tanzania Daily News
DR Sunday Alfred Dominico, a specialist in Obstetrics and Gynaecology, is a Lecturer in Obstetrics and Gynaecology, Research and Publications Coordinator at the School of Medicine and Dentistry, University of Dodoma (UDOM). Recently, Dr Dominico, who is a Consultant for World Lung Foundation on maternal health (External Communication), granted this exclusive interview to Our Staff Writer,

JAFFAR MJASIRI, in which he analyses major challenges in ending women's death during pregnancy and childbirth. Read excerpts...

Q: Why do women die during pregnancy and childbirth?

A: According to the latest (2012) countdown 2015 report, that tracts the worldwide efforts in attaining MDG 4 and 5, Tanzania is among 38 countries that have been flagged as making insufficient progress in reducing maternal mortality.

The current maternal mortality ratio in Tanzania is 454 per 100,000 live births, with actual numbers estimated at about 7000-11000 deaths per single calendar year. The World Health Organisation (WHO) delay model, identifies three phases (levels) of delay (barriers) that women face in achieving the timely and effective medical care needed to prevent deaths occurring in pregnancy and childbirth.

The first phase relates to delay in decision to seek care. The major factor here is the low status of women in their families and communities. This could be due to the low level of education, cultural beliefs, social dynamics and any other factor that could affect women's decision to seek care. When it comes to medical care seeking, the first step is for the person to recognise that she has a problem and the next step is for her to seek the needed and appropriate care.

In a situation where decision is made by others (husband, mother-in-law, aunt) the woman might perceive the problem but her decision to seek care definitely would be affected by those who decide for her. Phase two concerns delay in reaching care; In some cases, the pregnant woman and society around her might have made the decision to seek medical attention, and yet they cannot reach the care facility because of physical, geographical and economic barriers. Majority of women in rural areas are staying in places that are more than five kilometres from the nearby health facility and might not have the fare to reach the facility.

In other cases poor condition of the roads and geographical barriers such as flooded rivers might be contributory. The third phase is delay in receiving adequate health care. The woman and her family might have made the decision (whether late or timely) and successfully reach the facility but the human and material resources at the facility might not be adequate or skilled or motivated enough to deliver the appropriate care.

The inadequate referral systems to secondary or tertiary facilities are likely to lead to poor maternal outcomes in complicated cases. Comprehensive Emergency Obstructive Care is among the proven interventions aiming at averting maternal suffering and death which should be combined with interventions targeting other identified gaps in a particular community to achieve optimum maternal outcomes.

Q: How is Comprehensive Emergency Obstetric Care (CEmOC) achieved?

A: The concept of Comprehensive Emergency Obstetric Care (CEmOC) originated from the fact that five of the major causes of maternal mortality - haemorrhage, sepsis (infection), unsafe abortion, hypertensive disorders and obstructed labour - can be treated at a wellstaffed (number and skills), wellequipped health facility. There are a number of signal functions (activities) that define CEmOC, which are to be performed by a well trained practitioner (skilled attendant).

These include performing Cesarean section, safe blood transfusion, manual removal of retained placenta, parenteral antibiotics, parenteral oxytocic drugs, parenteral anticonvulsants, manual removal of placenta, assisted vaginal delivery and evacuation of the uterus for women with incomplete abortion. The challenge in our country is that only less than 10% of Health centres are performing CEmOC while the target in our national maternal and neonatal mortality reduction plan (One plan) is to have at least 50 per cent of Health centres and all hospitals performing CEmOC by 2015.

Q: Is it true that Traditional Birth Attendants (TBAs) can affect maternal outcome?

A: We have had mixed perceptions on the impact of TBAs on maternal outcomes. In the past we used to believe that TBAs are essential and critical link in achieving better maternal outcome during pregnancy and childbirth. However, it has been noted that TBAs could lead or contribute to the first phase of delay as outlined in the WHO delay model.

As TBAs are not skilled enough to detect severe complications of pregnancy and childbirth. Some of the pregnant women with complication might be delayed to reach the appropriate care and subsequently causing poor maternal and fetal outcome.

As TBAs are close to the community, and as they have been practicing for a long time, they might build a false sense of security to the women under their care and thus predisposing pregnant women to severe complications of pregnancy and childbirth.

Q: Of course, this calls for intervention, so how do you go about it?

A: As TBAs are close to the community what is being done is to train them to be part of the solution (strategy) to reduce these delays. They are essentially trained to refer the pregnant women to the nearby facilities as soon as they attend to their home centres.

In some other areas such as Kigoma rural where the WLF Bloomberg Maternal Health Project is also operating, TBAs have been given incentives and motivation for each pregnant woman they refer to the nearby Health centres. I believe that if this approach is reciprocated by other similar settings in our country, we might be able to increase the percentage of facility deliveries from around the current 50 per cent (TDHS 2010) to higher proportions, which will definitely increase the number of women attended by skilled attendants (trained nurses, doctors and midwives) and thus improve maternal and fetal outcome.

Q: There are a number of women reported to be using traditional labour induced medicine, is there any risk for the maternal health of the mother and the baby?

A: We believe that there are local herbs such as castor oil, ginger, cotton seeds/roots, marijuana and blue Cohosh that might induce or accelerate labour. So when such substances are used by pregnant women they could lead to inappropriate strong uterine contraction which might lead to fetal discomfort and ultimately fetal death and ruptured uterus.

The situation becomes even more worrying when used in women with contraindications (restrictions) to normal vaginal delivery especially those with two previous cesarean deliveries or those with inadequate pelvis because of their body size or previous pelvic trauma or infection (polio) or cases with extensive genital scars due to previous Female Genital Mutilations (FGM).

Q: How do you overcome this condition?

A: The best way is to change the society and local community's perception on the use of labour inducing local herbs. Despite the known anticipated good effects, local herbs could lead to the above mentioned complications. Attitude and perception change is a process that takes time but the fruitful results can be achieved through continuous and persistent education to communities.

Q: How significant is Cesarean Section in solving Induced Labour complication?

A: Cesarean section as an intervention is normally done to optimise maternal and fetal outcome whenever complications arise during pregnancy and childbirth. So in cases where the patients are seen at the health facility before the complications have reached fatal levels, Cesarean section could prevent such complications.

Despite these important expected positive outcomes, Cesarean section, like any other major surgery procedure, can be accompanied by a number of complications such as anaesthetic complications, too much blood loss during the procedure, injury to other organs such as the urinary bladder and increased risks of post delivery infections.

And beyond that the C-section compromises chances of possible virginal delivery in subsequent pregnancies. Essentially if you have someone who has had a C-section, if she is pregnant and she is expecting to deliver, you could opt to do another repeated elective (planned) C-section or you could try normal delivery and if it fails revert to C-Section.

However, for those with two or more C-section should be performed before the onset of labour because of higher risks of uterine rapture. For those who have had C-Section for recurrent indications, for example the pelvis is too small; in this particular case you cannot try normal delivery, instead go directly to C-Section. C-section should only be performed when there are right indications.

Q: Another option of getting rid of unwanted pregnancy is through abortion, what is your comment?

A: Each year, throughout the world, approximately 200 million women become pregnant and among them 40 % (80 million) are unwanted and of these, 40 million end up with abortion. 20 million pregnancies end up with unsafe abortion- that is abortion done by either unskilled person or in an environment lacking the minimum required standards or both.

East Africa is the worst hit region worldwide. In Tanzania abortion is a critical problem and if you visit regional hospitals, half of admissions in gynecological wards are due to abortion or its complications. An abortion is among the five leading causes of maternal mortality, contributing to 13% of all maternal deaths. So it is quite a big and challenging problem.

This could be due to limited access to family planning services. Only 34 per cent of married women (2010 TDHS) are using family planning methods and thus exposing them to the risk of unwanted pregnancies. In a country like Tanzania where abortion is illegal, these people are likely to end up with unsafe abortion and thus exposing them to various complications such as infection, massive blood loss, maternal death and future risk of infertility.

Q: How does a woman prepare to conceive and deliver?

A: The first part is about the family preparation on when to have a child. So this entails the whole process of family planning. On the second part, when the woman is pregnant she should be prepared to carry the pregnancy and prepare for delivery.

On delivery the woman should be prepared psychologically and be educated on individual birth preparedness. In this particular case they need to draw an individual birth plan that addresses issues like, when to deliver, where to deliver, material and resources needed for logistical and social support.

There is a need to effect change of community mindset that the community should look at pregnancy as a normal condition that is liable to cause complications if not well handled. Pregnancy requires both planning and coordination for optimum outcome.

• Tanzania