MOBILE PHONES HELP MANAGE OBSTETRIC FISTULA IN TANZANIA

When Dorothea got up on a rainy morning in the small village of Makundi, she could not have imagined the nightmare her life was about to become. As she prepared food for her three children and husband, she didn’t know that two days later she would wake up in a hospital bed after losing her baby and suffering severe internal damage, leading to a dreadful birth injury — obstetric fistula.

Delay

It was getting dark when Dorothea first felt the pain of labour and quickly asked her mother to call the local traditional-birth attendant. For the next 11 hours she would lay on a small mat on the muddy floor of her house. Each passing hour increased her suffering to an almost unbearable level. The sun was already rising when the family finally took the decision to take Dorothea to a hospital.

First, a wheel cart was used to carry her to the nearest dispensary accessible by road. From there, Dorothea’s family had requested a car to pick her up, but heavy seasonal downpours had turned the road into an almost impassable mash; it took six hours for Dorothea to be on the road to the hospital. A flat tire further delayed the journey. It was getting dark again; Dorothea waited for another car in a blur of throbbing pain. When she eventually arrived at the hospital, the only doctor had already gone home for the day. They sent for him; when he returned to help Dorothea, what she delivered was a dead baby.

Referral system

In Tanzania, giving birth remains risky. Even if the latest maternal mortality estimates show a slight improvement globally, every year an unacceptably high number of women die in childbirth and from pregnancy-related causes in the country, where maternal mortality rates have not changed in the last ten years. For every woman who dies, 20 other will suffer birth injuries. The real tragedy is that most of these deaths and injuries are preventable.

“Persistent high maternal deaths and disabilities are one of Tanzania’s greatest challenges today,” said Dr. Julitta Onabanjo, UNFPA Country Representative.

Less than half of all births in Tanzania take place in a health facility. Lack of transportation and poor infrastructure are still major reasons for the delay in seeking medical assistance. With an average distance of 30 km to reach a hospital in rural Tanzania (Household Budget Survey, 2007), women can spend several days travelling to the nearest health facility.

Yet, even when they reach a hospital in time, it is often ill-equipped or under-staffed to provide the needed care, particularly if presented with complications like the need for a Caesarian section. Basic emergency obstetric and neonatal care* is only available in five per cent of Tanzania’s health centres (Ministry of Health and Social Welfare, 2006). Dorothea was not among the lucky patients benefiting from those services.

Nightmare

Dorothea thought that nothing could surpass the tragedy of losing her baby; the numbing pain of the loss and 28 hours of labour made it impossible for her to move or think. However, the following morning the nightmare was still not over. She woke up in a puddle of urine.

She went back to her village leaking without stop, the sharp smell filling the small hut. A nurse at the local dispensary explained that she had developed an obstetric fistula. The birth injury — a rupture between the vagina and the bladder and/or the rectum caused by the pressure of the baby’s head during the many hours of labour — had left Dorothea incontinent.

Estimates suggest that approximately 1,200 new cases of obstetric fistula occur annually in Tanzania (Tanzania Fistula Survey, Women Dignity and UNFPA, 2001). Because they are usually ostracized by their families and communities, women with fistula tend to be isolated, often for many years. Sadly, most women living with the condition can’t afford it, or do not know that treatment is available.

Barriers

The barriers to safe delivery the women in Tanzania face are multiple and interdependent, ranging from wider development challenges such as infrastructure gaps, high poverty levels, gender inequity and lack of education, to health system deficiencies.

Experts would say that Dorothea would probably not have had an obstetric fistula —and her baby could probably have been saved — had she given birth in a nearby health centre with the assistance of a skilled health professional, like a midwife, who could have referred her to the hospital in time, despite the bad conditions of the road.

The availability of and access to skilled professionals working with adequate equipment and the necessary drugs and supplies are indispensable for the reduction of maternal and newborn mortality. The ability to take informed decisions about reproductive health issues could contribute a great deal: universal access to voluntary family planning, for instance, could considerably reduce maternal and newborn deaths.

Cultural beliefs, norms and a long tradition of giving birth at home are also among the major reasons that prevent women from seeking medical advice and delivering at health facilities. In addition, access to sexual and reproductive health services and information is still limited. When available, the information often targets only women, even though male involvement in family planning is considered crucial. Every fourth Tanzanian woman would like to plan her family, yet does not have the power to decide for herself or have access to the necessary services.

After one vain attempt to get fistula treatment in a regional hospital, Dorothea was referred to the Comprehensive Community Based Rehabilitation in Tanzania(CCBRT), Tanzania’s second largest provider of obstetric fistula surgery. There she underwent a successful surgery. Although the majority of obstetric fistula cases are treatable, the lack of information about available resources and in-country capacity can delay, sometimes for years, the full recovery of patients.

In the halls of CCBRT other women like Dorothea wait for surgery, all with similar stories. The majority of them are poor women who lack access to health-care services. This is why the centre provides fistula surgery free of charge. Yet the high costs of transportation and accommodation still make treatment a luxury.

Mobile phones

New mobile phone technology is changing this scenario and helping women so they don’t have to face the ordeal endured by Dorothea.

In 2009, UNFPA and CCBRT formed a partnership to assist women with fistula overcome two major barriers: lodging and transportation costs. The partnership enabled CCBRT to remodel an old hospital ward into a hostel where women can wait for and recover from surgery.

Simultaneously a new scheme was introduced which allows CCBRT to pay transport costs via mobile phones using Vodacom’s M-PESA technology.

Money is sent from CCBRT’s mobile banking account to CCBRT ‘ambassadors’ across Tanzania, who help increase identification, notification and transportation of fistula patients. The ambassadors — usually doctors, nurses or NGO-workers — can retrieve the money at their local mobile company agency and buy the patient’s bus tickets. Upon the patient’s arrival at CCBRT the ambassadors receive a small incentive via the same mobile banking system, called M-PESA: M for mobile and PESA for money in Kiswahili.

Previously CCBRT had a monthly average of 14 fistula surgeries; in March 2010 this increased to 29 fistula surgeries, the highest monthly number of fistula operations ever seen at CCBRT.

Despite continuous efforts, Tanzania, like many other countries in Sub-Saharan Africa, has a long way to go to achieve MDG 4 and 5, to reduce maternal and newborn mortality by 75 per cent. Providing fistula services is just part of the solution.

“Efforts have to be made to support the implementation of national plans, such as the Primary Health Service Development Programme, to improve primary health care services and to ensure availability of well-equipped and staffed dispensaries, health centres and wards, as well as basic and comprehensive emergency obstetric care in all primary, secondary and tertiary health facilities,” said Dr. Julitta Onabanjo.

Although Dorothea will be reunited with her family soon, the pain she has gone through will not be forgotten: “When I go back home I will tell my story and let them know how important it is to give birth at a hospital because you can never know what might happen.”

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Tanzania is among the first countries to launch the “Delivering as One” initiative. UN agencies are working together with the Government of Tanzania and other national partners in a joint programme to support the reduction of maternal and newborn deaths in the country.

Working within and beyond the health sector and managed by UNFPA in partnership with UNICEF, WHO, UNESCO, ILO and WFP this multi-sector partnership builds upon a wide range of skills, knowledge and expertise.

For more information, please contact: Friederike Amani Paul, Special Assistant to the Representative, fpaul@unfpa.org.

* Basic emergency obstetric and newborn care, provided in health centres, large or small , includes the capabilities for the administration of drugs like antibiotics, oxytocics, and anticonvulsants; manual removal of the placenta; removal of retained products following miscarriage or abortion; assisted vaginal delivery, preferably with vacuum extractor, and newborn care.