On my first day working as an OB/GYN at a rural hospital in Tanzania, I was called urgently to the operating room for help. A pregnant patient had been admitted with such a severe dental abscess that her face was disfigured from the infection. Two hours ago, the medical staff had performed a procedure to drain the abscess, but the patient was still in the operating room. Swelling from the abscess had obstructed her airway and the patient was unable to breathe without assistance. I asked for a fetal Doppler to assess the baby, but unfortunately, not long after I arrived, the patient's oxygen saturation decreased, and we could no longer feel her pulse. We started CPR and they tried to intubate her, but in the end were never able to get an airway. I made a decision to perform an emergency C-section to save the baby, but my heart sank even further when I found not just one baby but undiagnosed twins. We tried to resuscitate them but never got heartbeats. The hospital staff had responded to the best of their ability and resource capability; but in a short period of time, three lives were lost that day.
I spent a year working and teaching in a hospital that served a catchment area of almost 725,000 people and performed about 10,000 obstetric deliveries per year. I went abroad to teach principles of OB/GYN to medical officer students who were not receiving the training they needed. When I arrived in mid-2013, the hospital had three MDs and no specialists. In Tanzania, there is one doctor per 100,000 people. In comparison, the United States has one doctor per 300 people. A ratio of 1 doctor to 3,500 people in the United States is considered a health care desert, and the worst areas in the U.S. have a ratio of 1 doctor to 7,000 people1. Tanzania is in the top five countries with the most newborn deaths in sub-Saharan Africa2.
In the year 2000, United Nations member countries agreed on eight Millennium Development Goals (two of which focused on reducing child and maternal mortality) to try and achieve by 2015. This past week, many of us toasted to the coming of a new year, but the midnight countdown also marked a deadline that sub-Saharan Africa will not be able to meet.
It is easy to get overwhelmed and disheartened by the global situation. I certainly did at times.
But if we do not chip away at the larger issue slowly, the obstacle will never get smaller. Maternal mortality was not cut to the extent targeted by 2015, but there was significant progress made. Globally, the maternal mortality ratio dropped 45 percent from 1990 to 2013. A litany of issues contributed to the deaths of this mother and her twins: social issues, cultural issues, barriers to seeking antenatal care and medical treatment. What can we focus on? What can we target in this seemingly insurmountable list? World leaders are reconvening to discuss the post-2015 development strategies, and according to the Secretary-General of the UN, the "core" of the agenda will focus on Sustainable Development Goals (SDGs).
Countries in east Africa know that they need more health care professionals and trained birth assistants. A larger, stronger health care workforce would enable more patients to get seen sooner, more frequently and closer to where they live. A laboring patient trying to reach a hospital might not require the three days it takes her to travel from a remote island in Lake Victoria to the mainland. Medical student numbers are actually increasing in Tanzania, but faculty numbers are down. Students in Tanzania want to learn, but they lack the teachers they need to develop and educational resources are limited. Focusing on capacity building to sustainably strengthen a health care workforce is a key move in continuing to improve the health of women worldwide.
The close of my first day working in Tanzania left me shaken from the lives we had lost as a result of a preventable medical condition; but the close of my year left me hopeful that the students, physicians and nurses I had taught would carry on the lessons learned to further improve maternal health in their country.
1Gaskin et al, 2012
2newborn analysis Tanzania
About the author: Maureen Ries, MD is an Obstetrician-Gynecologist and Deputy Chief Medical Officer for Seed Global Health, a capacity building organization that partners with the Peace Corps to form the Global Health Service Partnership (GHSP). Dr. Ries taught and worked in Tanzania through the GHSP and is an Assistant Clinical Professor in the general department of OB/GYN at the University of California, Irvine.