This is the second in a series of stories about Jhpiego’s work in support of the Tanzanian government’s efforts to strengthen and improve health care for women and families.
Tanga, Tanzania—In a community hall in this sisal-growing region of Tanzania, nurse-midwife Halima Omari Mhando realized for the first time that a tactic she used to hasten birth was absolutely the wrong thing to do. Not only was pressing down on the mother’s belly inappropriate, it could harm the pregnant woman and her baby, she said.
That was just one of many take-away lessons for Mhando and 24 other nurses, midwives and health officers enrolled in a special training program aimed at building capacity, strengthening health systems and preventing the needless deaths of women and newborns in health facilities across Tanzania. In short, with new skills, they are learning how to avoid a tragedy and provide exceptional care and support to women giving birth.
As part of a Jhpiego-supported, national government program, the health providers who work at often crowded and undersupplied health centers, small clinics and local hospitals are attending a course in basic emergency obstetric and newborn care (BEmONC) and infection prevention. They are participating in the U.S. Agency for International Development-funded Mothers and Infants, Safe, Healthy and Alive (MAISHA) program, which seeks to reduce maternal and newborn deaths through competency-based training and facility improvements. Maisha in Kiswahili means healthy living.
Mhando said she wasn’t the only health provider at her workplace who would exert pressure on a woman’s abdomen to try to push the baby out. But now, “I’m going to go back and tell them the adverse effects of doing it”—possibly rupturing the uterus and causing internal injuries to the mother and baby, she said.
From demonstrating basic infection prevention measures, such as proper handwashing, to introducing the concept of supportive care, to reviewing use of the partograph as a decision-making tool, the course for MAISHA providers combines classroom instruction and clinical skills labs with work in the hospital. In this way health providers can get hands-on experience performing a new technique or updated skill. Trainers then follow up with supervision and coaching visits to ensure that the newly trained providers are performing up to standard in their health facilities.
“Most of these facilities have many clients with complications during pregnancy, labor and delivery, the postpartum period and with the newborn baby. Now they will be able to identify any danger signs that need immediate care, and they will be able to provide care according to standards,” said Scholastica Chibehe, a midwifery advisor for Jhpiego. “Most women give birth in their local health centers, and now they will be able to receive the most updated care by skilled health personnel.”
The program is needed because so many rural health centers and dispensaries don’t have replacement staff, and their health providers are kept too busy to update their clinical skills. “If they don’t know how long a term pregnancy is, how can they know if a mother is overdue and needs to be referred to the hospital for the proper mode of delivery before the baby dies in the uterus?” said Mary Sapali, a BEmONC national trainer. “Or if the woman is in preterm labor, and the baby is delivered, the provider needs to ask herself, ‘Can I take care of this baby here?’”
According to Sapali, proper use of the partograph is a specific skill that needs strengthening. “There is no proper system to ensure that these rural clinics and centers have partographs and use them. The partograph helps with so many things, to know the exact progress of labor for both fetus and mother. It will help a health provider make the appropriate decision if the woman needs to be transferred to a higher level facility.”
Nurse Mhando candidly admitted her lack of knowledge with the partograph. “I was guessing on how to monitor the contractions,” said Mhando, who has been working as a nurse for the past 14 years. “I was just looking at it with my eye. But now I understand it very well . . . to assess how many contractions in 10 minutes and the duration of each contraction—20 to 40 seconds is moderate, above 40 seconds is strong and less than 20 is mild.”
A key component of the updated skills course is supportive care of the pregnant woman. Sapali, the BEmONC trainer, explained the concept in one phrase: “Put yourself in someone else’s shoes.” Give the pregnant woman as much information as will make her feel safe and confident; encourage her to labor in the birthing position of her choice; and provide nurturing care to help make her labor easier. Research shows that “continuous empathetic and physical supportive care is associated with shorter labor, less medical and epidural analgesia and fewer operative deliveries,” Sapali pointed out.
Ngereza Deodata, the nurse in charge of maternity care at Bombo Regional Hospital in Tanga, is a maternity ward veteran. She too was candid about how she could benefit from the skills sessions.
“As an in-charge nurse in a maternity ward at a hospital, we are from very old-fashioned training and very old-fashioned procedures with care of patients,” she said, during a break in the course. “After this (training), we are updating our skills and know them well. It is easy for us to change the behavior of our colleagues and supervise them.”
Through courses such as this, providers can help improve the skills of other health workers and build their capacity to deliver competent care to women and newborns. Such transfer of knowledge strengthens health systems in a district, a region or the entire country.
For several participants, some aspects of the course served as a way to check themselves and their care.
During the session on eclampsia, a potentially fatal, pregnancy-related blood pressure disorder, nurse Anna Meshack Kaduma recalled the pregnant woman who arrived in her maternity ward in Pangani District one night last fall suffering from convulsions. It was her first case of suspected eclampsia—the second leading cause of maternal deaths in developing countries. Drawing on her nursing school studies, Kaduma performed several appropriate practices—she injected the woman with magnesium sulfate and lidocaine to ease any pain, took an ultrasound to check on the fetus and called for a doctor.
But as a result of the training, Kaduma learned that placing the woman on her left side would have helped relieve any pressure on the fetus and would have kept the mother’s airway open. Kaduma also found out that liver damage is a potential consequence of this hypertensive disorder.
“I’m glad I came,” said the 24-year-old nurse who works alone in a small dispensary in Makalamo village.
With Jhpiego’s help and support, Kaduma has joined a legion of health care providers in Tanzania who are working tirelessly and skillfully to save women’s lives.