A Medical Emergency

A case in the Tanzanian city of Moshi late last year reveals how suddenly a seemingly normal labor can turn into an emergency in which every second counts. Hawa Khalidi, 36, who had five normal births, gave birth to her sixth child a few hours before dawn on Nov. 19 at a health center staffed only by nurses in one of the poorer sections of the city.

Then she began to hemorrhage, and by daybreak she was dead.

An autopsy found that Mrs. Khalidi bled to death because the nurse who delivered her baby failed to perform one basic task, essential to prevent deadly bleeding: removing the placenta after she gave birth.

Normally, pulling on the umbilical cord will extract the placenta. But the autopsy revealed that the cord broke off. The nurse apparently did not know how to reach into the womb to remove the placenta. She sent Mrs. Khalidi to a hospital, but by then Mrs. Khalidi had lost so much blood that doctors could not save her.

In an interview, Mrs. Khalidi’s husband said nurses at the clinic had scolded her because she was too poor to bring her own “delivery kit” containing gloves, clamps and other supplies. Some maternity wards are so crowded that women sleep two or three to a bed, or lie on the floor, along with their newborns. Although the government has promised to build more clinics and to put one within three miles of every village, it cannot even fully staff the clinics it already has. Health workers  overworked, underpaid and sometimes poorly trained  often become demoralized and resigned to the high death rates.

Women lack education and information about birth control, and some become pregnant too young to give birth safely. Husbands and in-laws may decide where a woman gives birth and insist that she stay at home to save money. Malnutrition, stunted growth, malaria and other infections, anemia and closely spaced pregnancies all add to the risks.

In rural areas, many women use traditional birth attendants instead of going to the hospital. The attendants usually have no formal training in medicine or midwifery. Many doctors blame them for high rates of maternal death and complications, saying they let labor go on for too long, cannot treat complications and fail to recognize emergencies that demand hospital care. But many women are loyal to them. For one thing, the price is right. Around Berega, they charge about $2 per birth. A normal birth at the hospital costs about $6, an emergency Caesarean $15.

Dr. Jeffrey Wilkinson, an obstetrician from Duke University who is working at the Kilimanjaro Christian Medical Center in Moshi, pointed out that other African countries, like Niger, had even higher maternal death rates. Despite the many obstacles in Tanzania, “there is hope here,” he said.