Dilemma of maternal death reviews

By Catherine Mwesigwa Kizza

After the infamous Mbale hospital maternal death, Dr. Pius Okong, the head of the Health Service Commission together with offi cials of the Association of Obstetricians and Gynaecologists visited to conduct an audit.

They found a huge arch being constructed at the entrance of the hospital yet the maternity ward had only five beds on which the midwives admitted and delivered mothers. The maternity ward had an overwhelmed intern and a newly qualifi ed comprehensive nurse.

The midwife at the post natal ward had finished her work at 10:00am and was chatting with patients oblivious of the load in the maternity ward.

“There needs to be a policy to empower staff in critical wards like casualty, maternity, theatre and special care units for babies to call for help from any other wards when they are overwhelmed,” he says.

“Allocation of duty rota assumes that patient flow is constant but these wards are unpredictable. That is why mothers die,” he adds.

He advises that maternal death audits look at whether systems are working well including the human resource challenges and not victimise individual health workers.

Maternal death reviews or audits investigate the causes and reasons of the death of any mother due to childbirth and pregnancy-related causes.

“When a mother dies in the hands of a health worker, many times many other mothers would have survived. An anonymous audit helps to identify not only the skills gap of the health workers but the system failures,” he says.

“When the process is not anonymous, you may not be able to get to the bottom of the system issues,” he says. He notes that there is a human resource management challenge in the country across all sectors including the health sector.

“Supervisors fear to reprimand any unbecoming behaviour. They do not discipline or appraise workers. When a maternal death occurs, the audit is used as a scapegoat,” he says.

Dr. Eve Nakabembe, an obstetrician/gynaecologist who participated in some of the first maternal death reviews in Mbarara hospital reveals that before they started the audits six years ago, the death ratio at the hospital was up to 1,900 women for every 100,000 live births.

The audits identified gaps and consequently reduced deaths. Prof Lewis who has headed the United Kingdom Confidential Enquiries into Maternal Death for 20 years, was in Uganda last year to conduct workshops for health workers on how to audit maternal death cases.

She is an advocate of maternal death reviews as a means of improving services for women and their children. “Maternal mortality ratios are just estimates. What they show is usually half of the real picture of maternal and new born deaths,” she says.

She adds that after the UK instituted maternal death reviews, they were able to capture previously unknown information.

Their 1994 – 1996 report revealed that some of the women who died were the socially excluded, very young, or from minority ethnic groups. One of the reasons was that they could not speak English.

As a result the UK government changed its maternity policy to resolve this challenge.

The audits in the UK are done not only in the health facility but in the community and family of the dead woman as well.

“It is a way of going beyond the numbers of women who die, to recognise that behind each number is a woman who had children, a husband, family and community,” she says.

The reviews are aimed at uncovering the bottlenecks that lead to the death of mothers with the aim of making changes to save other women.

However many health workers confess to have found the process frustrating.“You keep fi nding the same challenges and nothing is done to solve them. This is especially true for the infrastructure issues that need to be handled by other departments,” a midwife said.

For others it is the fear of blame that erupts every time a maternal death occurs.

“We are professionals and we are trained to save lives. Why is it that the health professionals are only blamed but their working circumstances are not looked into when maternal deaths happen,” a midwife who preferred anonymity in order to speak freely asks.

In 2008, the Ministry of Health declared maternal and new born death a notifiable case. This means that when a mother dies investigations have to also involve police and the Resident District Commissioners.

“This creates fear among the staff and it is diffi cult to get to the crust of the  investigations,” a senior obstetrician or gynaecologist consultant explains.

“In some cases, documents are  tampered with and fi les disappear making the   investigations incomplete and unusable,” a health worker who spoke on condition of anonymity said.

Prof Lewis explains that maternal death reviews are supposed to be confi dential and anonymous to yield meaningful solutions to challenges.

She adds that no names of victims, health workers or health facilities are mentioned to allow for confi dence in disclosure of information on the cases.

“This is to protect the health workers from unnecessary litigation and yet provide an environment to dig up any issues that may be hidden for fear of that. When there are no names, lawyers cannot victimise any health worker,” she says.

Reliable sources confirm that the obstetrician/gynaecologist at Mbale hospital was so harassed by the process and has left the country.