摘要：Inadequate health care and long delays in obtaining care during obstetric emergencies are major contributors to high maternal death rates in Tanzania. Formative research conducted in the Mwanza region identified several transportation-related reasons for delays in receiving assistance. In 1996, the Cooperative for Assistance and Relief Everywhere (CARE) and the Centers for Disease Control and Prevention (CDC) began an effort to build community capacity for problem-solving through participatory development of community-based plans for emergency transportation in 50 villages. An April 2001 assessment showed that 19 villages had begun collecting funds for transportation systems; of 13 villages with systems available, 10 had used the system within the last 3 months. Increased support for village health workers and greater participation of women in decision making were also observed. THE LIFETIME RISK OF maternal death is about 300 times greater in Tanzania than in northern Europe, 1, 2 and long delays in obtaining care during obstetric emergencies contribute heavily to these high death rates. In the study area, the Mwanza region of Tanzania, poor roads, long distances, a lack of vehicles, and lack of family or community planning for getting to health care in an emergency were identified as major reasons for delays in obtaining care. Formative research included a random-sample baseline survey of community members and 110 in-depth interviews with community leaders, health care providers, traditional healers, traditional birth attendants, current and former village health workers, teachers, and mothers and fathers from both higher- and lower-income groups. These data showed that no community had plans for providing emergency transportation for urgent obstetric care and that most people believed that transportation was the sole responsibility of the mother or her family. These data guided development of a train-the-trainer curriculum on community empowerment. Ten participants, selected from community leaders, government health workers, elected officials, and CARE staff, became “master trainers.” Participation in problem identification and decision making, especially by women, was a key theme in the master trainers' curriculum, and all meetings were facilitated by the trainers (see Ahluwalia et al. 3 for full details). Master trainers conducted meetings with leaders from 50 communities, who then arranged communitywide meetings to discuss development of emergency transportation plans. Community assessment tools were developed to monitor progress on transportation plans and on the level of community participation in decision making (who participated and to what extent). Periodically, each village is rated on 3 factors: (1) emergency transportation plans (progress in, development of, and use of); (2) supportive supervision (quality of work by village health workers—for example, the number of referrals of mothers with danger signs for difficult pregnancies, the number of material registry cards completed, and the quality of maternal counseling); and (3) ownership of health problems by the community (level of participation by all sectors of the community in decision making and level of responsibility taken by the community in addressing health and other problems). Transportation choices varied according to the geographic location and economic situation of the area. Many plans changed over time, some because of changes in village leadership, some because the initial choices were not possible or too expensive, and some because more attractive alternatives became available. One community had planned on using a canoe, but heavy growth of elephant grass and water lilies made passage impossible. Another village tested a model tricycle but found it too difficult to use and decided on an oxcart. Other plans proved adaptable. Village elders from one community were returning with materials to build a new canoe when their boat capsized and they drowned. The village decided to try again. More funds were collected and the village now has a functioning boat system. At the time of the last assessment, in April 2001, choices for transportation were as follows: motorboat or canoe (10 communities), a bicycle with a trailer (2), a modified tricycle with platform (22), an emergency fund (5), a tractor with a trailer (4), a reconditioned vehicle (5), and an oxcart (2). Twenty-eight communities had written action plans, 19 had collected some funds or materials to implement the plan, and 13 had plans that were functional (could be used if needed). Ten communities have used their transportation plans in the last 3 months.
