Birth-Tanzania styley!

While I know the title comes across as a bit of a generalisation, I must remind readers what I write only reflects my experiences, at a specific place and a specific time, with specific people.

So, yet another landmark date arrived. My first day on placement here in Tanzania.

I was very quiet that morning as we had breakfast and on the drive to the hospital. From the experiences the other girls had already shared with me I was really nervous; and I was so glad I wasn't starting the placement on my own-Valerie and Beverly were working today too. 

It was a public holiday so I was told that the matron of the hospital who oversees all elective students and volunteers wouldn't be in. So instead of meeting her, I was taken straight to the maternity unit. I had an idea of what the unit looked like from photos I'd seen online so ina weird  way things looked kind of familiar. We got changed and I had a very brief tour of the unit. There were 3 main rooms - the antenatal room which had about 12 beds for anyone who had been admitted in early labour or with PIH etc. this led onto the labour room. First there was an alcove with a bed, closed off with a curtain, this was often used as a triage area for antenatal admissions. Past this moving clockwise was a counter top with weighing scales and a wipe-clean, cushioned mat which was the neonatal resuscitation area. Above this counter there was an emergency cupboard with some resus equipment and a selection of drugs. Then there was a trolley which had 3 large metal tins which looked a bit like pressure cookers! These stored sterile equipment such as scissors, clamps, needle holders, etc. Then there was 3 incubators which resembled wooden cupboards where infants were kept warm with small electric blankets or hot water bottles (with covers of corse). Then there was 2 labour beds with heavy duty plastic sheets, side by side with plastic curtains to offer some privacy, however these weren't always a good fit, so there was often gaps. Past the second bed was a large, 50s style cot that could easily fit 5 babies in! This was mostly used as an extra counter top. Then there was the drugs cupboard and some storage cupboards. Along the fourth wall of the room was the desk where new admissions were seen, all midwives and doctors paperwork was completed then 3 doors to the clinic room; the staff room (which had 1 table, 2 chairs and was also a storage room and at times also used for clinics; and the sluice - 3 bins for different waste products and a huge 'trough' with a cold tap at one end and a drain at the other. When it came to cleaning there was only cold water, and detergent when available (which was most of the time). The labour ward then led onto the postnatal room where again there was approximately 12 beds but at times extra beds were squeezed in when necessary (leaving no leg room between beds) and no cots. All women co-slept with their newborn and on one very busy day, there were 2 women to some beds.

So in a labour ward with such limited place it may be unnecessary to point out that these women birth alone-the only birth partner is the woman in the adjacent bed! Family brought flasks of chai and pans of stew for women-if they had family close enough to visit. One thing I really admired, although I didn't figure it out until further on in the placement, was the solidarity of the women supporting each other in these wards; either sharing food, calling the midwife for someone in the opposite bed, encouraging each other during the first stage of labour and looking after each others newborn while washing etc. Especially for the primigravida women, this must have been such a relief when no family were available.

While Beverley went to observe a caesarean, Valerie and I stayed to watch a birth. The women stay on the antenatal ward until they feel things are progressing, then they bring themselves through to the labour ward, lay their kanga (gorgeous pieces of fabric used as clothing, headscarves, swaddling and sheets) on a bed, strip off and climb up onto the bed waiting for a midwife to come and assess them. If she's not yet fully dilated, she's asked to return to the antenatal ward. If she is fully dilated then she remains on the labour ward and progresses alone, even when second stage commences. The women are phenomenal! They remain active and mobile until second stage, they are fairly quiet throughout their labour, completely focused on their body and birthing their baby, with no pain relief. Once pushing commences they are on the bed, mostly supine, either holding behind their knees or on their ankles. I only heard one midwife 'manage' second stage, telling the woman to push, all other births I saw were physiologically led by the woman's body and own involuntary pushing. I did observe several midwives almost provide an assisted delivery-as soon as the head was delivered, they didn't wait for restitution or the next contraction, they pulled the body out of the birth canal. When I enquired why, I wasn't really given an explanation. On one occasion I was told it was because she needed to get that baby out quickly to make sure it was OK but when they don't regularly listen to the fetal heart during labour, and the liquor draining had been clear for this birth I couldn't see any evidence as to why the fetus would need a prompt delivery. There may have been a valid reason, just not one that I could identify.

Once the baby was born, oxytocin was administered IM, cord cut, the sex of the baby shown to the mother and it was wrapped in a kanga and weighed. The baby then remained either by the scales or in an incubator while third stage was completed, the perineum checked and sutured if required, then the mother was wiped down and made her way to the postnatal ward. Quite often the woman had walked herself and carried her belongings to the postnatal ward within 15 minutes of giving birth! On one hand I was in absolute awe of the ability and attitude of these women to just crack on. On the other, I was very conscious of the lack of care during the immediate postnatal period for these women and was more surprised by the lack of care for neonates, but that's another story.

Overall my first day felt like a baptism of fire! I knew resources were limited and demands on staff were high but experiencing it was completely different to any expectations I had. I found it hard to observe women birthing with no support or regular checks-mostly due to the limited staff being needed elsewhere so they couldn't provided one-to-one care. And when something did require the attention of a senior midwife, I'm sure try got sick of us mzungu shouting 'Sister! Please come.' And hearing about the caesarean was v.interesting and again, will make another interesting jackanory!