Hospitals and Maternal Death in Tanzania – Guest Post by Adrienne Strong

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image Adrienne is a PhD candidate in sociocultural anthropology at Washington University in St. Louis. She has been traveling to and conducting research in Tanzania since 2007 and returned in January 2014 to continue her dissertation research related to the causes of maternal mortality within health facilities. Instead of focusing on the clinical causes of maternal death in these settings, Adrienne’s research focuses on the ways in which the social and institutional environment of the hospital and a bureaucratic medical system influence maternal health outcomes.

 

 

When I first arrived at my field site at the regional government hospital in the far southwest corner of Tanzania in February, only one of the doctors assigned to maternity was actually present on the ward. He alone was responsible for rounding on patients, conducting the weekly OB/GYN clinic, handling the majority of the operative cases from the obstetrics and gynecology wards, and he was the only one on call for these services every night for more than two weeks. I asked where everyone else was and was told they were attending various seminars and trainings. This particular hospital, like most health facilities in Tanzania, almost constantly operates with a large personnel deficit. Despite this deficit, in any given week there is almost always at least one nurse or doctor (or both) from maternity attending a seminar or training or otherwise away from the ward. In maternal death audits conducted by the hospital and the regional health administration, one of the action points often written includes a call for more training of health providers. I have asked a number of doctors and hospital administrators about the efficacy of these trainings and if the seminars lead to better outcomes and reduced deaths. At an annual work-planning meeting held in May, one doctor working with an organization that partners with the Ministry of Health and various other NGOs said,

 

“We have a lot of trainings which have been done, but the challenge is: are those trainings effective? Are those people implementing those skills they have been trained on? I have been moving around to the facilities and they go back there and don’t change anything.”

 

In a conversation the night before, I told this doctor all these seminars are so much water down the drain, money just going nowhere, if these people go back to their places of work and are unable to apply what they have learned. He agreed that this seems to be a recurring problem and implementation of new skills is an ongoing challenge. Though he said the above statement in front of the entire region’s project staff, not one person engaged with his skepticism. Beyond the routine mention of “supportive supervision” as an important part of the organization’s work, there was no discussion about how to more effectively ensure providers return to their facilities and practice their new skills with confidence and accuracy.

 

I had a conversation with one of the doctors at the regional hospital about training of staff, in relation to recognizing signs of shock, and why, if they have received on the job training or other opportunities to learn new skills, were they unable to implement those skills to save lives? He said it was an attitude problem. This is the recurring refrain: An attitude problem. The nurses have an attitude problem. The providers all have an attitude problem. When I ask the next logical question-then how do we change these attitudes?- there are no suggestions, simply a vague attitude of resignation; no one has any ideas. From my research thus far, and this is at the root of what I am investigating, it seems attitudes and motivating factors of health care providers are not well understood. No one, not even the managers and leaders of these nurses and doctors, seems to know what makes them tick or lose motivation and, subsequently, what makes them lash out at patients or neglect them or offer poor quality care incommensurate with their training and knowledge level. Some health care leaders have a very cynical perspective and say it’s only about money; the providers don’t have a heart for their work. I find this to be a blanket statement, lacking nuance and optimism, a poor representation of what is most surely a more complicated issue. Where is the breakdown when it comes to implementing new training and new ideas? Is it that attitudes and activities have become routinized and entrenched, making it virtually impossible to imagine a different present, let alone to realize one? Is it a crisis of leadership and vision? It often seems that even those senior nurses on the maternity ward are defeatist when approached with new programs or ideas for improving their work environment and the care they provide. Routines have become a way of life and de-routinizing in order to recreate modes of action and care seems to be an almost impossibly difficult task.

 

As one program director said, it seems like all these trainings and seminars aren’t working “if we aren’t improving the services for the end user, the women who come to give birth.” Administrators and planners and NGO representatives might sit in their offices and say, “Check! Check! Check! Our people are fully trained, they’ve gone to so many seminars and refresher courses, surely our care is excellent now!” Then I enter the maternity ward and still see women being hit and told “you are killing your baby!” when they have a difficult time pushing in order to give birth. In a focus group discussion with women in the community, they told me that the number one reason women develop complications and die in the hospital is because of the harassment of the nurses. Perhaps these women are being overly critical of the nurses and not taking responsibility for their own actions, as nurses have suggested to me. However, when I broke down the lists of reasons a woman might develop complications and die that the community women gave me, a full 45% of the responses related to the behavior of women and the community and 42% of the reasons related to the behavior of nurses, the remaining 13% were medical conditions such as anemia or HIV/AIDS. The women were, if anything, harder on themselves than on the nurses. Harassment from nurses was the most frequently cited reason for developing problems, reflecting a deep dissatisfaction with the care that is available and reflecting the individual experiences of many women. Nurses were charged with being corrupt and looking at “the condition of a person” to determine if she was someone with money or not, and therefore meriting expeditious care or not. The nurses were also accused of adding to the “ndugu-lization” of health care. This appears to be an ironic and derisive use of the term “ndugu,” or brother, that was used during Tanzania’s socialist era to encourage a happy type of fraternity among workers and farmers. In this case, the woman is accusing health providers of only looking out for their own relatives and close friends, providing preferential treatment to those they know, providing better care to those that know how to find them at home.

 

In light of all of this, then, what good is all the money that is spent on these trainings and seminars if the trainees return to their posts without being able to use their new skills? I’m not advocating for a cessation of seminars and training programs, far from it, but I am saying that we have neglected a vital piece of the puzzle. By not thoroughly examining what drives and motivates health care providers at all levels and in all types of facilities, everyone is throwing some of their money away. The maternal mortality rate in the regional hospital has actually gone up over the last three years. Perhaps paired with these seminars needs to be a more sustained and thorough supervision program that provides leadership coaching and routine performance feedback and evaluation for providers in a way that allows them to air grievances and share ideas. Currently, at this hospital and in many other facilities in the region, there are very few mechanisms to recognize providers who consistently deliver high quality care and there are only opaque and drawn-out mechanisms to discipline providers who consistently make mistakes or provide abusive care. There needs to be leadership, commitment, and accountability at all levels of health care and within all cadres of providers. In this way, health care workers can perhaps be more effectively enabled to practice their skills to the full extent of their training and ability, to think creatively and to solve problems as they occur with the tools at hand. Clearly, if providers are lacking clinical knowledge and the basic tools of their trade it will be impossible to drastically improve maternal health outcomes, but not every piece of the puzzle, not every possible route to improving care, requires more gloves, more magnesium sulfate, or book knowledge.