During my second trip to Tanzania, I got the chance to explore more of the country’s health care map, especially where antenatal care is concerned. Let me take you on a tour of a local hospital in Moshi, where nearly all WHO-requirements are met, except perhaps in the field of ultrasound.
In this hospital, all pregnant women receive rapid tests for HIV, malaria and syphilis during their first antenatal visit. Their blood group is defined and their height taken, since women under 1 meter and 50 centimeters are considered here to be at high risk of cephalopelvic disproportion and of having a c-section. Furthermore, during all consultations a urine dipstick is done, their blood hemoglobin level is defined, and they have their blood pressure taken manually and their weight registered. The fundal height is taken by tape measurement, while the fetal heartbeat is checked using a horn of pinard.
As a matter of routine, women are given three kinds of drugs during pregnancy: Sulfadoxine/Pyrimethamine as malaria prevention, Mebendazole against several parasitic worms, and an iron supplement (basically a combination of ferrous sulphate and folic acid, to counter low levels of iron in their blood). Furthermore, their tetanus vaccination status is checked and, if need be, updated, and they are checked for signs of oedema and other pregnancy related complaints. Above 20 weeks of pregnancy, they are also routinely asked about fetal movements.
Husbands are invited to join their pregnant wifes for the first consultation. Practice shows that they are not necessarily keen on doing this, but the free medical checkup (HIV test, body weight, blood pressure, Mebendazole) has proven to be an effective incentive. It is a great advantage for nurses to be able to give health and nutritional education to both partners, since an informed husband will be more intended to support his wife in a healthy lifestyle.
Generally, pregnant women pay this hospital 6 antenatal visits. The outcomes of these are documented on the government provided standard pregnancy cards which are used obligatorily all across Tanzania. However, while generally useful, these cards leave no room for the outcomes of ultrasound checkups. This particular hospital is a private one, connected to a company in the Moshi area. The bulk of the expectant mothers visiting it, are employees or their relatives, and they all receive at least 2 free ultrasound scans. For the remainder of the patients, the situation is much like that in most hospitals in Tanzania, where antenatal ultrasound scans are not standard procedure; they are offered, but only if there is a medical indication and at the patient’s own costs, which many cannot afford. Free antenatal ultrasound checkups are available in rural areas, but dispensaries often lack either the equipment, or the personnel trained to use it. As a result, the number of women in Tanzania who receive at least one ultrasound checkup before 24 weeks of gestation (as is recommended by the WHO), is relatively low.
In this hospital, the ultrasound room is equipped with a GE Logiq C5 premium. The radiology technician showed me their procedure. During every scan two prints are made, one of the fetal heart rate by using the m-mode setting and one of the gestational age based on what is measured (often only the femur length). There are no specific protocols on how to perform an obstetric ultrasound scan and neither are there protocols on defining the estimated due date (EDD) based on ultrasound. They often keep shifting the EDD based on the last ultrasound made. This often leaves intrauterine growth restriction and macrosomia undetected.
Last but not least, HIV+ mothers are put on medication. If the viral load is under control, they are allowed to breastfeed until their child is 1 year old. Babies of HIV+ mothers are given Nevirapine in the first 6 weeks, after which they receive a DBS test. ‘DBS’ stands for Dried Blood Spot test. The sample is collected by piercing the baby’s skin with a lancet and collecting drops of blood on special absorbent filter paper. After several hours of air drying, the samples are stored in low gas-permeability plastic bags with desiccant added to reduce humidity. They are then sent to a specialized lab for analysis in order to define the baby’s HIV status. DBS test material remains stable in tropical climates, which reduces the likelihood of a false positive result and allows its use in rural, resource poor settings. After the baby’s status has been defined, it is followed up regularly up to the child’s first birthday.
Based on what I have seen in Tanzania so far, both in this hospital and in general, it seems that they are making good progress in meeting the WHO’s 2016 recommendations on antenatal care. An even greater deal can be gained if the recommendation on antenatal ultrasound care (to offer all pregnant women at least one scan before 24 weeks of gestation) takes further shape in practice. Shoulder to shoulder with the local partners, Midwife Without Borders hopes to continue to contribute to this.
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Resources used
World Health Organisation (2016). WHO recommendations on antenatal care for a positive pregnancy experience.