Safer Motherhood

Worldwide, each minute of every day, a woman dies of complications due to pregnancy or childbirth. In addition more than 20 women are seriously injured or disabled during labour every minute (Read this story). Reducing the maternal mortality is one of the Millennium Development Goals, see: http://www.undp.org/mdg/goal4.pdf

Tanzania mainland total population is estimated at 33,584,607(National census 2002) with 75% of the population residing in rural areas. The number of women of reproductive age (15 -49) is projected to increase by 1 million in the next five years from 9 million in 2005 to 10.1 million in 2010. Since 1996 total fertility rate has remained relative constant at 5.7 children per woman, whereby rural women have higher fertility rates than those residing urban areas (TDHS 2004-2005).

Maternal health reflects both society’s level of development as well as the performance of the health care delivery systems.Tanzania has an unacceptably high maternal mortality rate: 578 per 100,000 live births indicating no changes since 1996 (TDHS 2004-5). Although this approximate figure could be an overstatement of the real number of maternal deaths, it clearly shows the gravity of the situation. One in every 16 women in Tanzania dies because of complications related to pregnancy and childbirth, compared to one in every 2800 women in developed countries. This figure places Tanzania among the 10 countries which contribute 61% of global maternal deaths. This remains to be a major public health challenge for the country.

Some of the reasons given for Tanzania’s high mortality rates include inadequate access to health services thus only 64% of the hospitals provide comprehensive Emergency Obstetric Care (EmOC) , 5.5% of the health centre level are able to provide EmoC . The percentage of health facilities able to provide Comprehensive Post abortion Care (CPAC) being limited to 5% only. Lack of skilled human resources both in number and skill mix are also some of the bottlenecks with 32% of the required human resources are in place; for example one third of the District hospitals have no Medical Doctor, there are only 87 Obstetricians and Gynecologist population out of which 30% are located in the City of Dar es Salaam. Of the 21 regional hospitals only 5 have Obstetricians and Gynecologist specialist the rest are placed in tertiary and private practices.

Unmet demand for family planning is another constraint affecting maternal health. Currently the modern contraceptive prevalence rate in Tanzania is 26%, compared to 18.4% in 1996 (TDHS 2004-205), nevertheless there seems to be a decline in the past 2 years. This is partly attributed to the facts that everything is sideswiped by HIV and AIDS activities. It is believed that maternal deaths could be reduced if enough commitment is directed to services and to the beneficiaries of the services.

Socio- cultural factors contributing among other things to high risk pregnancies (too early or too late), forced marriages, low socio status of women in the society leaving them with no say in taking decisions about their sexual reproductive health etc). With regards to too early pregnancy, 25% of the young women are mothers before reaching 18 years of age.

The levels of care given to women during delivery are other determinants for her survival and that of her baby. Fifty three percent (53%) of births occur at home, sometimes with a Traditional Birth Attendant (19%) or relative (31% to assist her or even without assistance (3%). Many unpredicted difficulties or complications can arise and in the absences or access of skilled assistance the situation becomes more critical. Regardless of high Antenatal attendance which is reported to be 94% less than half of the women (47%) are reported to deliver in a health facility with 46% of these women ending up assisted by skilled personnel. Skilled attendance to women in the highest wealth quintile is 87% compared to 31% in the lowest wealth quintile a serious concern with regards to equity. Delivery by caesarean section is 3% this is far below WHO- recommended standard of 5-15% (TDHS 2004-005).

The majority of maternal death (80%) occurs during childbirth and in the immediate postpartum period. The cause of death is divided into direct (obstetrical) causes and indirect causes. Direct causes of maternal death are: bleeding, abortion complications, obstructed labour, hypertension and infections. Indirect causes of maternal death are diseases that are aggravated during pregnancy such as AIDS, malaria, anemia and tuberculosis. Other factors such as poverty, poor nutrition, low empowerment of women, cultural factors, poor communication / referral system to include limited availability of ambulances, poor road infrastructure other logistical factors and competing demands on the health system –other emerging disease burden e.g. malaria, Tuberculosis, HIV/AIDS also contribute to maternal death. Women’s perceived barriers to access health services are lack of money (40%), the long distance to the facility (38%), having to take / hire transport (37%) and unfriendly service providers (14%). Other possible hindrances that women often encounter on their way to acquire treatment are:

When delivering at home, it may take time to recognize complications
Decisions to seek care at the nearest health facility can be delayed for many reasons, e.g. because the decision has to be made by husbands or family members, traditions may hinder women to seek care, or they may avoid consulting health services for fear of negative attitudes of service providers
Additional time will be required to find money and transport to reach a health facility
The nearest health facility may not be equipped or may not have skilled personnel to provide the needed emergency obstetric care
Referral to the next facility providing obstetric care may be difficult, again due to problems in decision making, transport or lack of funds
At the hospital further delays can arise due to slow decision making, lack of equipment or skilled personnel or lack of funds to purchase supplies for treatment

All these factors lead to an unacceptably high maternal mortality and morbidity.

A related issue is the high number of unwanted pregnancies in Tanzania as a result of poor knowledge on, lack of access to and availability of contraceptives. Illegal and unsafe abortions often lead to complications and can result in maternal deaths. It is estimated that if one could avoid all unwanted pregnancies, the amount of maternal deaths could be reduced by 25%.

Poor Antenatal, intrapartum and postnatal care results in a high number of babies who die during delivery. This has a direct bearing on the maternal mortality again as women will often become pregnant very soon after their baby died and before their bodies have recovered from birth. There many missed opportunities to improve the health for those women coming in contact with formal health services. For example during ANC or post partum attendances. About 65% of the women have their blood pressure measured, 54% have blood samples taken for hemoglobin estimates and syphilis screening, urine analysis 41% and les than half (47%) are informed of the danger signs in pregnancy. Care after delivery is mostly directed to the well being of the child. This is well illustrated by the fact that 83% of women who delivered a live birth outside the health facility did not receive a postnatal check-up and only 13% were examined two days within giving birth.

Tanzania has since 1974 struggled to established and developed policies and reforms that prioritized maternal and child health services. Of recent the recognition and commitment of the government to focus on the continuum of care through provision of effective essential packages to Mothers, Newborns and Children is well captured in the “One Plan National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008- 2015” (MoHSW / RCHS April 2008) .The government of Tanzania is making extra effort to prevent malaria in pregnant women through provision of two doses of SP for intermittent preventive treatment and (IPT) and distribution of Insecticide Treated Nets (ITNs) to pregnant mothers. Other interventions directed to mothers are Prevention of Mother to Child Transmission of HIV, prevention of anemia through free supplements of iron and folic acid and provision of effective modern contraceptive methods.

TGPSH is active in combating the high maternal mortality in various ways:

Sexual health education to prevent teenage pregnancy & unwanted pregnancies
Support piloting for Emergency Oral Contraceptive pills
Involvement of male wide range of the community in addressing maternal and infant health
Support community to be aware of their reproductive rights and to demand quality services
Training of medical personnel in long-term and permanent family planning methods
Training of medical personnel in comprehensive post abortion care
Support to Lindi Region by an obstetrician/gynaecologist in order to train local doctors in obstetrics and specialised gynaecological surgery such as treatment of obstetric fistula
Support to quality improvement initiatives in health facilities, e.g. quality circles

Improving accessibility of family planning methods via support of community based services CBDs