Late one evening at the Idodi Health Centre in the southern highlands of Tanzania, nurse-midwife Neema Mlunza had just begun her shift. Everything appeared to be routine. Her colleagues had left to escort a patient via ambulance to Iringa Regional Referral Hospital—80 kilometers away—and her only patient, an HIV-positive mother of four, was in labor but with little trouble.
As the mother gave one last push, Mlunza guided the new baby boy into the world. The nurse-midwife cleaned him and wrapped him in warm clothes. Then, within one minute after delivery of the baby and checking that there was no twin in utero, she gave the mother a shot of oxytocin to help the uterus contract and started delivering the placenta. Despite these steps—all of which follow national clinical protocols — the mother started bleeding uncontrollably.
“Something was not right,” she recalled. “The uterus had not contracted. I calmed the mother, explained to her what was going on and the steps I was going to take to stop the bleeding.”
In Tanzania, postpartum hemorrhage—excessive blood loss within 24 hours after childbirth—is the most frequent cause of maternal deaths, accounting for nearly a third of all 13,000 pregnancy-related deaths occurring yearly. Because it can quickly lead to shock and death if uncontrolled or untreated, it is important for health care providers to be prepared to handle cases of postpartum hemorrhage.
Patients such as Mlunza’s are exactly the kind of women that the Jhpiego-led Mothers and Infants, Safe, Healthy and Alive (MAISHA) program is working to reach. Under this program, Jhpiego works with the Ministry of Health and Social Welfare to reduce maternal and newborn deaths by equipping health care providers such as Mlunza with skills to make the right decisions and take appropriate actions in time. Supported by the U.S. Agency for International Development, MAISHA is one of the many innovative programs through which Jhpiego works to prevent the needless deaths of women and families in Tanzania.
In countries such as Tanzania with high numbers of maternal deaths and limited resources, introducing low-cost, evidence-based practices to handle birth complications such as postpartum hemorrhage is an important way to improve and save lives. MAISHA introduced these evidence-based practices by providing competency-based training in basic emergency obstetric and newborn care (BEmONC), as well as equipment and supplies, to 771
nurse-midwives in Tanzania.
As a result of this training, Mlunza knew she needed to move quickly when the mother began to bleed uncontrollably. She ran an intravenous line with Ringer’s lactate solution and injected the mother with the appropriate amount of additional oxytocin to help replace lost body fluids and contain the bleeding. Mlunza then began to apply external compression by massaging the woman’s abdomen with her hands to help the uterus contract and stop the bleeding.
But the bleeding continued. She needed a second pair of hands and called for the clinical officer on duty, who happened to be her husband. As he monitored the mother’s vital signs—the woman’s blood pressure had fallen dangerously low and her pulse rate was very high—Mlunza switched course and began internal compression of the woman’s uterus to try and stanch the flow. Talking to the mother in a comforting tone, she continued applying the lifesaving skills she had learned through the MAISHA program.
“With my surgical gloves on, I inserted my right hand into the birth canal to compress the lower part of the uterus. And then I placed my left hand on the abdomen and applied compression for five minutes,” said Mlunza. “After releasing, I felt something pulling. . . the uterus was contracting…the bleeding was slowing down, and after a few minutes, it stopped altogether.”
After making sure there was no more bleeding, Mlunza placed the swaddled newborn on the mother’s chest for the skin-to-skin contact that is essential to begin the bonding process—another lesson learned in her BEmONC training.
“We stayed with the mother and new baby boy for 24 hours,” Mlunza said. “In the meantime, I gave the newborn nevirapine for HIV prophylaxis and made sure the mother completed all the doses for prevention of mother-to-child transmission of HIV.”
To minimize the risk of transmission through breast milk, all HIV-exposed infants should receive antiretroviral prophylaxis, which in Tanzania is nevirapine until one week after cessation of breast-feeding. Mothers in Tanzania are counseled to exclusively breastfeed their infants for the first six months, followed by the introduction of complementary feeding with continued breastfeeding until 12 months of age.
When the mother and child recently visited the clinic, Mlunza was thrilled to see them. “I keep following up on their progress. Mother and child are doing very well. The confirmatory HIV test results for the baby came out. He was negative. And the mother—she does not miss her clinic days at our HIV care and treatment center,” the nurse-midwife said proudly.
“Without the new skills I acquired from the MAISHA BEmONC training, we were going to lose this woman,” said Mlunza. “We have lost many [women] like her in the past. But now through me, nine of the 13 health providers at the health center have acquired these lifesaving skills—starting with my husband, (the clinical officer)—who was amazed how I was able to do this with confidence.”