Every 90 seconds, a woman dies during childbirth. in rwanda, women in rural villages have little or no access to emergency services such as cesarean deliveries, which are only offered in the district hospitals. In Tanzania, four out of 10 deliveries take place at a health facility, but only five percent of the health centers provide emergency obstetric services.
This disparity is caused by a lack of health providers trained in emergency obstetrics. With more training, health care workers, nurses and midwives can often prevent or treat the causes of maternal death, like postpartum hemorrhage, eclampsia, sepsis and obstructed labor.
Since 2008, Duke physicians and fellows have trained more than 500 health workers in Rwanda and Tanzania. The Advanced Life Support in Obstetrics (ALSO) Program was pioneered by Duke physicians and is now led by collaborators from Kilimanjaro Christian Medical Centre and Kigali University Teaching Hospital.
Duke Global Health OB/GYN Fellows Ayaba Worjoloh and Ruchi Puri have provided on-site training in Tanzania, and Nathan Thielman and medical students Shahrzad Joharifard and Nazaneen Homaifar have assisted with monitoring and evaluation in Rwanda. Evaluations show that participants learn the skills they need to deliver healthy babies and keep mothers safe.
Since the training began three years ago in Dodoma, Tanzania, maternal deaths have dropped from 17 to four. Plans are under way to expand the life-saving training to more rural areas and integrate the training into medical school curricula.
Tackling Complications of Childbirth
For women who have a successful pregnancy, many still face risks that could determine whether they live or die. obstetric fistula is a complication caused by obstructed labor that damages the soft tissues of the vagina. While more hospitals and clinics offer fistula repair surgery across low- and middle-income countries today, DGHI researchers warn it is not enough.
Obstetric fistula is a painful and traumatic experience both physically and emotionally. Women can lose their baby and experience problems like infertility and leakage of urine and feces, as well as fear, worry, stress and shame.
DGHI researchers Kathleen Sikkema and Melissa Watt and DGHI Doctoral Scholar Sarah Wilson are working with KCMC collaborators to identify and treat the psychological impacts of Tanzanian women with obstetric fistula. Through the Studying Obstetric Fistula and Trauma (SOFT) study, the research team found a large majority of fistula patients screened positive for either depression or post-traumatic stress disorder (PTSD). Women with fistula also had significantly less social support. The Duke research team is working with KCMC to develop and test a targeted mental health intervention that involves group therapy at the hospital. They anticipate promising outcomes among the women, and the treatment could be integrated into care across other low-resource settings.
Duke researchers are also taking an innovative and creative approach to address another common complication of childbirth, which is the transmission of HIV from mother to child. Recognized by USAID’s Saving Lives at Birth Grand Challenge, an innovative ketchup packetlike pouch is being used to stop the spread from HIV-infected mothers to newborns. Developed by Duke’s Pratt School of Engineering and DGHI faculty Robert Malkin, the plastic-lined foil pouch holds a pre-measured dose of anti-retroviral medication for newborns that has an extended shelf-life. When newborns receive anti-retroviral drugs shortly after birth, their chances of contracting HIV are cut significantly. Without a low-tech, high-impact innovation like the ARV pouch, many babies who are born at home may not get access to the life-saving medicine in time.
Training the Trainer: A Success Story
Dorah Mrema had been a practicing midwife at KCMC in Tanzania. A turning point in her life came when she was trained in emergency obstetrics by Duke physicians in 2008. Mrema is now equipped with advanced skills to teach other nurses and midwives in emergency obstetrics and address a huge need in her country.
“We previously didn’t have the skills to handle obstetric emergencies like postpartum hemorrhage and eclampsia, but our collaboration with Duke made it possible for us to learn those advanced skills,” said Mrema. “I can tell you 100 percent that maternal mortality has been decreased in Moshi and surrounding areas, so lots of good things have resulted from the Duke-KCMC collaboration.”
Today, Mrema continues to work as an instructor in the ALSO program and with Duke physicians and trainees on Duke-KCMC maternal health research. She is also excited about expanding her medical expertise to respond to another challenge facing a growing number of women in Africa: cervical cancer. As scores of nurses and health care providers like Mrema are trained in emergency obstetrics in Tanzania, it has the potential to produce a ripple effect on the lives of women and their newborn babies. Giving birth doesn’t have to mean death; it can mean new life.
4 out of 10 deliveries take place at a health facility, but only 5% of Tanzania's health centers provide basic emergency obstetric care.