When labour calls and it is a six-hour journey to help

By Erick Kabendera
KAGERA – At 40, Stella Fitani has gone through the joys and pains of giving birth all of five times. But it is the memory of Mugisha, her fifth child, now a year old, that remains enduring.

On a cool night in March last year, the last thing Stella expected despite being in advanced pregnancy, was to go into labour. And yet that is exactly what happened. And it all happened very fast. As soon as the pangs struck, she experienced a sinking feeling. In this remote village on Kinagi Island on Lake Vitoria, there are no clinics or health centres. Even if they were lucky to have one, it is very unlikely it would have come fully equipped with such a fancy accessory as an ultra sound scan. This means that for many women like Stella, there is no estimation of a date of delivery. They tick off the months in their own way and it is almost guaranteed that the baby’s arrival will catch them unawares.

But on that March night with her own baby’s arrival clearly imminent, and unlike with the other children, Stella was struck by a strong feeling that something was likely to go wrong this time. „I don’t know why I felt that way. I just felt it,“ says Stella.

It was her fifth pregnancy since she got married twenty years ago. She delivered her first two children on the mainland at Kagondo Mission Hospital in Muleba district, a six-hour boat journey, where she got access to better medical facilities and doctors. She had delivered her third born and then her forth pregnancy of twins with a traditional birth attendant on the island and everything had gone smoothly. This time, her husband, Adolf Lufintani, a fisherman had no money on him to get her to a hospital and it soon became very clear that since it was at night, she could only end up in the hands of Cecilia, her least favourite of three traditional birth attendants on the island.

Cecilia Sipirian is as respected as she is feared among the women (and men) on this island. Although she has made successfully interventions where has averted some tragedies, Cecilia is more known for her no-nonsense style of handling expectant mothers. She is not averse to spanking and yelling at those who are being economical with their energy during labour and for this reason, she is often the rescuer of last resort.

”She is also my neighbour; just three metres from here,“ says Stella while pointing towards one of the many small huts nearby.

Under Cecilia’s charge, Stella was relieved when her baby finally came out. But worse was to follow as the placenta failed to turn up and she began to bleed profusely. Cecilia barked at her urging her to push but to no avail.

After a protracted effort to try and deliver the placenta, Stella started to fear for her own life. Moreover, the bleeding still hadn‘t stopped.

Everybody who had escorted her, including her husband Adolf, pleaded with Cecilia to help save Stella’s life. But Cecilia, after administering one of the secret herbs she uses in such emergencies, began to lose hope too. She told them plainly that there nothing more she could do and advised them to take Stella to hospital. Hospital? Yes, Bukoba Government Hospital. This would require hiring a boat for Sh30,000 and then buying fuel for Sh18,000. They would also have to pay Sh20,000 to the fisherman who would ride the boat. The dizzying amount sounded like a death sentence for Stella. „That was a difficult alternative since my husband didn’t have that money,“ says Stella. ”I was worried and could see death coming.“

As she lay helplessly in front of her family and the birth attendant, Stella thought of the other women she knew around Kinagi and the other islands who had died from birth complications. She remember months back when one of her friends was giving birth at a traditional birth attendant‘s home and the baby almost faled to come out. The mother started bleeding. The birth attendant feared that she would die on her hands and referred her to Kagondo Mission Hospital. Luckily for the woman, she gave birth on the boat before they reached the hospital. But she never recovered from what she described to her friend Stella as the „shame“of delivering in front of a boat full of men.

”How can one deliver in the middle of men?“ Stella wondered as she narrated her story to me.”Birth is private and exclusively for women; men should never see a baby coming out.“

Cecilia, the traditional birth attendant who has been practising for more than 20 years, believes the reason Stella experienced difficulty with this particular pregnancy is because she had had a prior Caesarian section. She says she had stopped delivering mothers a year before she moved to the island in 1990 after local government banned traditional birth attendants in Bukoba Rural saying they had no formal training and were responsible for increasing maternal deaths.

However, she says she found it difficult to sit and watch helpless women suffer and she soon began to offer her help. Dr Charles Kilaro, an Ob-Gyn and a senior lecturer at Muhimbili University of Health and Allied Sciences says failure to deliver a placenta causes severe bleeding, which is one of the major causes of maternal deaths.

„We always advise traditional birth attendants to forward such cases to hospitals and health centres for intervnetion,“ says Dr Kilaro.

For Stella, Bukoba was not an option – on account of the exorbitant cost of getting there. The only alternative they were left with was to travel to the next island, Bumbire, a one-hour boat ride, where Dale and Christina Hamilton, the missionaries for the Africa Inland Church have set up a health centre. They had to find Sh10,000 to hire a boat to get them to the island.

But Stella was unlucky. Upon arrival at the health centre, Christina Hamilton examined her but decided that it was best to refer her to Bukoba. “We were at least comforted that if she couldn‘t treat me, she would give us the boat to Bukoba,“ says Stella.

The United Nations ratified a set of eight objectives – called the Millennium Development Goals at the UN Millennium Summit in September 2000.

Goal four of these MDGs targets reducing by two thirds of the mortality rate among children under five while goal five aims at reducing three quarters of the maternal mortality ratio. Although the targeted deadline for achieving these goals is 2015, there are many concerns that some of them might not be met.

There are concerns that the pace towards improving maternal, newborn and child health is slow and that the situation is further exacerbated by a lack of political attention. It is a situation that is quite glaring in Kinagi and its 24 sister islands.

According to the World Health Organisation, the lack of political will could be one of the reasons 57 percent of women are still delivering at home without access to health facilities in Tanzania. Government and its health partners last year launched the Tanzania National Partnership for Maternal, Newborn and Child Health with its head as Gertrude Mongella, the President of the Pan-African Parliament. Not surprisingly, Stella has never heard of the initiative. But she is more conversant with Hamilton and her husband who arrived on these islands 20 years ago and have almost singlehandedly attended to the mothers and children in their moment of need.

The Hamilton‘s mobile clinic visits Kinagi once a month, giving the women there an opportunity to receive prenatal, obsestrical and neonatal care. Apart from Kinagi, the couple has set up health centres in Ikuza and Bumbire Islands.

At the Bumbire health centre when I visited last month, women and their children sat on straw mats waiting for their turn to see the nurses on duty. These are some of the nurses that Christina has trained to provide health services to the people. Since the centre opened last year in February, it has attended to more than 4,000 people excluding mothers and children under five. There is a large waiting room while a smaller room acts as the doctor’s office with a small bed for examination. Christina says starting the dispensary was no mean feat. It took the couple seven years to get permission to construct the health centre, as children and mothers continued to die at an alarming rate. „Some people were spreading false rumors that we were spies and many other things against us but the village leadership decided to go to the district council to push the issue so that the permit could be granted,“ she says.

Behind the health centre’s building, the foundation is being prepared for yet another building that will serve as a labour room with an in-patient facility of four beds. Patients will be kept for 12 hours after which serious cases may be referred to the mainland.

The mothers here, some of whom have been on their grave’s edge, are full of praises for the Hamiltons. They still recall that before the couple came, there was no clinic or health centre here. Ward leaders would send a traditional birth attedant to examine pregnant mothers but the women here claim she was not very helpful and often sent them home after only placing her ear against their stomachs. There were no vaccines administered to children or mothers and no health monitoring of any sort. Now, mothers like 29-year-old Ajirat James have nothing but appreciation for the Hamiltons.

Three years ago, while the Hamiltons were still pursuing their permit, Ajirat’s baby died en utero. She had concieved without knowing she had contracted gonorrhea. When she went in for delivery at Bukoba main, the baby was discovered to be dead and the doctor found out that Ajirat had an STD. „The baby had died weeks before it was delivered. I was later told at Kagondo Hospital that I contracted gonorehea before concieving,“ she says.

A recent research by Christina Hamilton found out that 80 percent of people of reproductive age in the fishing communities have STDs and most of them don’t know they do and they infect others as a result. Even those who know still engage in unsafe sex. The fishermen are highly mobile and when they leave their wives the women go on to find new men thinking that their spouses will never come back. And most don’t return.

But the Hamiltons can only do so much. They have limited resources and the people in need of health services are many. And not just health services. Food and schools are also in scarcity here. Some of the Hamiltons‘ patients are pregnant adolescent girls who have been sexually assaulted. „Pregnancy is the most personal thing for African women but they share their stories with me. There is nothing more rewarding than saving their lives,“ says Christina.

Dr Kilaro says a project to introduce the medication Misoprost, which helps control bleeding during delivery especially in remote areas is in the pipeline. But Dr Kilaro is pessimistic that merely establishing health centres will solve the crisis in the rural areas. He is concerned that health workers are still reluctant to work in these areas due to their accompanying lack of basic services and as a result, health centres set up there could end up unmanned. He believes that a policy by government that requires medical graduates of all levels to work in rural areas for at least a year would go a long way in giving relief to these abandoned citizens. „Some people says it would take 100 years for a medical graduate to work in rural areas. Alternatevely, people who are already there could be trained to handle such cases since many people live in rural areas,“ he says.

He also suggests that for places like Kinagi with no permanent health centre, pregnant women could be advised to temporaly move to town where they could have access to hospitals and clinics. But that option too is replete with its own weaknesses, not least the possibility of some women having no extended family to move in with and no money to use while living away from home. Dr Kilaro wishes for more public cooperation in building things like health centres instead of always waiting on government to do everything.

Women like Stella can’t stop wondering when government will ever step in to rescue the situation. Having lived to tell the story of the birth of her fifth child, Stella has vowed never to get pregnant again.

„I don’t want anybody telling me about giving birth again, I have see enough,“ she says as she breast feeds Mugisha whose names means „blessed“.