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The death of a mother, a young woman who had hopes and dreams for a happy future but who dies before her time, is one of the cruelest events imaginable. The short and long term impact of such a tragedy on her surviving partner, children, wider family, the community and the health workers who cared for her cannot be overemphasized. Yet despite considerable advances in maternity care and world class care provided by highly trained and motivated professional, good maternal health is still not a universal right in both developed and developing countries.
According to the United Nations report (UN) (2007) more than half a million (585,000) women continue to die each year during pregnancy or child birth and this poses a key public health challenge for the international community especially when it wants to achieve the fifth United Nations Millennium Development Goal (MDGs) which aims to improve maternal health and reduce maternal mortality ratio by three quarters between 1990 and 2015.
The vast majority of maternal death and disabilities can be prevented through appropriate reproductive health services before, during and after pregnancy, and through life-saving interventions should complications arise.
Of the estimated 585,000 annual death worldwide due to complications of pregnancy and delivery, 99% occur in the developing world. It is estimated that the highest risk from pregnancy occur in Africa, particularly in Eastern and Western Africa with over 1000 maternal death per 100,000 live births. Ninety percent of pregnancy related deaths occur in developing countries whilst the world major focus is on methods and strategies to reduce this burden, particularly for women in developing countries (WHO, 1998). From the two data captured in 1998 and 2007 that is 90% and 99% respectively, it is clear that the rate of maternal death has worsened for developing countries. Of all the maternal deaths, 80% can be potentially avoided by interventions during pregnancy, childbirth and postpartum period that are feasible in most countries.
A research done in Syria by Bashour, Khadra, Campbell et al (2009) indicated that there are direct medical causes of maternal death of which hemorrhage is the main cause which occurs during labour or delivery and poor clinical skills and lack of clinical competency are also major contributing factors to these deaths.
Similar study done by Maternal Health Project (1997- 1998) also identified the leading immediate causes of maternal death to include sepsis, hemorrhage, hypertension, unsafe abortion, obstructed labour. Again, structural factors that impede treatment of obstructed labour such as transportation, cost of emergency admissions and staff attitude and practices (Negligence) constitute a large contributory factor in impeding treatment of obstructed labour.
The focus of this scholarly paper is on clinical negligence as a contributing factor to maternal death. Section II of the paper is on definition, prevalence and implications of maternal death while section III looks at the general factors causing maternal death. Section IV talks about how clinical negligence contributes to maternal death, and section V provides conclusion and recommendations.
Maternal death has been defined by different individuals or institutions. According to Herrera-Torres et al. (2006) maternal death can mean the loss of a productive member of the household, the dissolution of the family, and economic and social difficulty for the children. Again, the Tenth revision of the International Classification of Diseases, Injuries and Causes of Death, (ICD 10) (2010) also defines maternal death as 'the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes'. This means that there was both a temporal and a causal link between pregnancy and the death. When the woman died, she could have been pregnant at the time, that is, she died before delivery, or within the previous 6 weeks have had a pregnancy that ended in a live birth or stillbirth, a spontaneous or induced abortion or an ectopic pregnancy. The pregnancy could have been of any gestational duration. In addition, this definition means that the death was directly or indirectly caused by the fact that the woman was or had recently been pregnant. Either complication of a pregnancy, a condition aggravated by pregnancy or something that happened during the course of caring for the pregnant woman caused her death. In other words, if the woman had not been pregnant, she would not have died at that time. Maternal deaths are subdivided into further groups as direct and indirect deaths.
Direct maternal deaths are those resulting from conditions or complications or their management that are unique to pregnancy, occurring during the antenatal, intrapartum or postpartum periods.
Indirect maternal deaths are those resulting from previously existing disease, or diseases that develops during pregnancy not as the result of direct obstetric causes, but which were aggravated by physiological effects of pregnancy. Examples of causes of indirect deaths include epilepsy, diabetes, and cardiac diseases. Some women die of causes apparently unrelated to pregnancy and these deaths include deaths from all causes, including accidental and incidental causes. These deaths would have occurred even if the woman had not been pregnant and are therefore not considered as true maternal deaths.
Late maternal deaths are defined as the death of a woman from Direct or Indirect causes more than 42 days but less than one completed year after the end of the pregnancy.
Death from maternal causes represents leading cause of death among women of reproductive age in most developing countries (United Nations, 2005) and a large proportion of these maternal deaths may result from poorly managed deliveries and many such deaths could be avoided if suitable care were given.
The global maternal mortality rate is 400 per 100,000 live births, while it is 830 per 100,000 in Africa, followed by 330 per 100,000 in Asia excluding Hong Kong, Singapore and Japan who have maternal mortality ratios of 7, 10 and 18 per 100,000 live births respectively, which compare favourably with the lowest ratios in Europe (WHO and UNICEF, 1996). China, by contrast, has a maternal mortality ratio of 95 deaths per 100, 000 (WHO and UNICEF, 1996).
Worldwide, 13 developing countries account for 70% of all maternal death (WHO, 2003) and according to United Nations report, (2003) African women are 175 times more likely to die during pregnancy and childbirth than Westerners. Overall, African women have a 1 in 16 risk of dying during pregnancy and childbirth, compared with a 1 in 2800 risk for women from a developed region.
In South Africa, the maternal death rate is 340 per 100,000 live births. Figure for neighbouring countries are Botswana 480 per 100,000, Lesotho 530 per 100,000 and Namibia 370 per 100,000 live births (World Bank and Safe Motherhood, 2003). Also in Ethiopia, maternal mortality ratio estimates 871 per 100,000 live births while in 2008, Nigeria's maternal mortality rate was estimated at 545 per 100,000 live births (National Population Commission 2009).
In Ghana the maternal mortality rate (MMR) ranges from a predicted ratio of 214 (WHO1999) to about of 586 (Hill 2001) per 100,000 live births, with considerable differences between the regions, particularly, with the deprived northern regions showing maternal mortality rate of over 800 maternal deaths per 100,000 live births. This high rate has made reduction in maternal mortality one of the major goals of several efforts including MDGs and Ghana Macroeconomics and Health Initiative (GMHI).
Implications of Maternal Death
Maternal mortality does not only significantly reduce life expectancy of women in reproductive age (Key, 1987); it also has very negative consequences for the children, families as well as communities of the women. For example, approximately eight million stillbirths and new born deaths which occur annually worldwide are due to poor maternal health care during pregnancy and childbirth (UNICEF, 2007).
Furthermore, a World Bank study from 1997 revealed that mothers often invest more money in food, education and medicine as men. Accordingly, their death has negative consequences for the welfare of the family (Jowett, 2000). For instance, children in Bangladesh under the age of ten that have lost their mother are three to ten times more at risk to die within two years than children with a mother. The death of a mother also means a reduction in the household income as well as a loss for the economy, as many women in developing countries contribute a substantial share of labour in agriculture and trade.
It is also argued that complications of pregnancy and delivery considerably strain overall health systems, as maternal illness is one of the largest contributors to the disease burden of developing countries (Goodburn & Campbell, 2001). For example, pregnancy and childbirths complications and abortions contribute notably to a health facility's expenditure as well as the need for hospital beds, which are often scarce in poor countries (Jowett, 2000). Therefore, if maternal and new born morbidity and mortality is not addressed effectively, it is estimated that by 2015, there will be at least 2.5 million maternal deaths and 49 million maternal disabilities. The consequences are at least 7.5 million deaths of children and US$ 45 billion loss in productivity in Africa alone (DRH, 2004). Altogether, investing in mother's health and preventing their death contributes to the health of children, poverty reduction and economic growth and therefore is crucial for the benefit of future generations (Jowett, 2000).
Overall, maternal mortality represents a large-scale, multi-factorial problem in most developing countries today, with severe consequences for families, societies and nations.
Factors Contributing to Maternal Death
Many interrelated factors contribute to maternal mortality. These include women's low status and lack of decision-making power, lack of information among women and their families on the signs of complications, inability to access care when complications arise, lack of resources to reach an appropriate care facility in time and medical service factors such as delay in treatment, lack of skills and errors of judgment (Hailu 2006).
Women's Low Status and Lack of Decision-Making Power
The high incidence of maternal death is one of the signs of major inequity spread throughout the world, reflecting the gap between rich and poor. Thus low level of economic development seems to have a significant impact on maternal mortality. According to Shiffman (2000), in low income countries of the world the MMR is higher than 25 per 100,000 live births mainly because wealthier nations have more financial resources to spend on public health, well-being and education. Again the research revealed that better-nourished mothers, as in developed countries, are more likely to stay healthy during pregnancy and less likely than poor women to experience birth complications. In developing countries, over 50% of women suffer from severe anaemia (UNICEF, 1998) and anaemic women are 3.5 times more likely to die in pregnancy than women without anaemia (Brabin et al, 2001).
The reproductive and health status of a woman as well as her health care behaviour, which reflects her use of maternal health care services, are strongly influenced by her socio-economic and cultural background (McCarthy & Maine, 1992). In many cultures and societies of developing countries where the status of women is low, maternal mortality is very high (Key, 1987). Often, cultural traditions support early childbearing and a high number of children may also prevent women from seeking health care, as mostly husbands and relatives make decisions on care-seeking of women (Lule et al, 2005). As revealed in a study in Bangladesh, 35% of interviewed women explained that their religion does not allow them to leave the house, particularly during pregnancy, and another 35% cited the objections of their husband and relatives as a reason for not seeking care (Cooper, 2004). Furthermore, more than 50% of women in most developing countries today do not participate in household decisions (Vadnais et al, 2006). Therefore, UNICEF (1998) claims that the low status of girls and women in society as well as a lack of education are the main reasons for too early, too many and unwanted pregnancies, which contribute to high levels of maternal mortality.
Lack of Information or Knowledge about Signs of Complications
Lack of information or knowledge can mean that women are unaware of the gravity of their own condition. Some health conditions may be so common in a community, and women may have suffered the symptoms for so long, that they are not even recognised as problems that need medical care, such as chronic reproductive tract infections. Some conditions, such as sexually transmitted diseases, may be hidden because they are thought to be shameful. Pregnancy can be another condition which is not perceived as requiring care, or which women do not want to admit to in early stages. Low self-esteem reinforces fatalism about health conditions including maternal illness. Women may not regard their own pain and discomfort as worthy of complaint until it is so debilitating that it may be too late. Hesitancy to seek care after domestic violence may also be attributable to women's lack of self-esteem or embarrassment (Timyan et al, 1993). All these contribute to maternal death.
Inability to Access Health Care Services When Complications Arise and Lack of Resources
Five types of obstetric emergencies account for most maternal deaths: haemorrhage (25 per cent); infection/sepsis (15 per cent); unsafe abortion (13 per cent); pre-eclampsia and eclampsia (12 per cent); and prolonged or obstructed labour (8 per cent). According to WHO,
UNICEF, the World Bank and other stakeholders, the majority of these maternal deaths and disabilities could be prevented through access to increased professional and sufficient care delivery during pregnancy and labour, especially access to essential obstetric care, safe abortion services, active rather than expectant management in the third stage of labour, and the use of anticonvulsants for women with pre-eclampsia.
Often, women have to travel great distances to the closest centre that offers quality maternal health services, especially when they live in rural and remote areas. An insufficient road infrastructure and undependable public transport or emergency transportation impedes access to care as well (Lule et al, 2005). As indicated in a research study in Malawi, of the 90% of interviewed women who wanted to give birth in a health care institution, only 25% were able to do so because of the great distance from their village (Lule and Ssembatya, 1996).
Consequently, many women have to depend on local health services from providers who often do not have the skills or the equipment to treat obstetric complications, such as relatives or traditional birth attendants (Lule et al, 2005). Moreover, most poor women in developing countries are constrained by the financial costs for health care. The cost of a birth with professional assistance or at a hospital can be costly and a caesarean section is more expensive (Gelband et al, 2001).
Even when services are financially and geographically accessible, women often do not receive the health care services they need. Many health facilities lack trained personnel and equipment to provide adequate maternal health care, especially those allocated in poor, rural or isolated regions (Lule et al, 2005). Again, lack of clinical knowledge and skills among some doctors, midwives and other health professionals, senior or junior, has been one of the leading causes of potentially avoidable maternal death. One of the commonest findings in UN report (2003) was the initial failure by many clinical staff, including General Practitioners, Emergency Department staff, midwives and hospital doctors, to immediately recognise and act on the signs and symptoms of potentially life threatening conditions. These unskilful practices in the health institution, mostly lead to gross clinical negligence.
As a consequence of all these constraints, the majority of women in developing countries today still deliver at home without the assistance of trained personnel, which contributes to a high number of maternal deaths (Vadnais et al, 2006).
In all, most of the above mentioned barriers to care are reflected in Thaddeus and Maine's (1994) three- delays model. As indicated above, the first delay occurs in the decision-making process, which is influenced by the woman herself, her husband and/or relatives, the status of the woman, her recognition of complications and the consideration of costs for treatment. The second delay of reaching a health facility is caused by the inaccessibility and distance of the health clinic and the non-availability or costs of transportation. The last delay phase characterizes the receiving of quality care after arriving at the health institution, which depends on the availability and quality of supplies such as blood transfusion or antibiotics, equipment and competent medical personnel with accurate judgement (Stekelenburg et al, 2004).
All these delays are interconnected (Ransom & Yinger, 2002) for example; the first delay can also be influenced by the last two. Especially when women and their families do not seek care because they know the distant of the hospital is far and the possibility that competent health personnel or appropriate judgement and treatment are not available (Freedman et al, 2005). Unavailability of resources, incompetence's and attitudes of some medical staff are becoming emerging critical factors that need to be addressed.
In Ghana, Maternal Health Project (1997/1998) revealed that staff attitude and practices constitute approximately 35% of contributory factors that impede treatment of obstructed labour which mostly leads to maternal death. Such figure is alarming and cannot be ignored.
Link Between Clinical Negligence and Maternal Death
Negligence is when someone who owes you a duty of care has failed to act according to a reasonable standard of care and this has caused you injury or damage.
Medical malpractice is professional negligence by act or omission by a health care provider in which care provided deviates from accepted standards of practice in the medical community and causes injury or death to the patient, with most cases involving medical error. Standards and regulations for medical malpractice vary by country and jurisdiction within countries.
According to Loudon (2000) doctors interventions may cause the increase in maternal mortality in higher social classes since it is plausible that they expose women to unnecessary interventions. Similarly, in 1933 the Public Health Relations Committee of the New York Academy of Medicine published a report that showed that 66 percent of the maternal deaths were due to malpractice and was preventable (Porges, 1985). The incorrect use of doctors' instrument deliveries (e.g., caesarean) and anaesthetics were two of the main causes of maternal death in the United States, explaining 61 percent of the preventable maternal deaths.
There are several cases that indicate gross clinical negligence and examples from Umtata General Hospital in South Africa are as follows:
A 38-year-old teacher living on the outskirts of Umtata was expecting her fifth baby. She had had 3 previous caesarean operations. At 35 weeks' gestation she was admitted to hospital with a blood pressure of 220/150 mmHg. There was protein in the urine and she was oedematous. An assessment of severe pre-eclampsia had been made and she was put on oral
Nifedipine, Magnesium sulphate and Hydralazine injections. The Cardiotocogram (CTG) showed fetal distress after admission and it was decided to perform an emergency caesarean operation. A lower segment caesarean section was done under general anaesthesia. A live baby weighing 2160 g was delivered. In the recovery room it was noticed that the mother had poor urine output. An intravenous injection of furosemide 80 mg was administered, with no rise in urine output. Thereafter she began to froth at the mouth. She was intubated and transferred to the intensive care unit where she had a cardiac arrest. Resuscitative measures failed and the patient was declared dead.
At autopsy, the woman was noted to have cyanotic fingernails, and moderate oedema of the feet. A copious amount of diluted haemorrhagic fluid was found in the peritoneal cavity, a sample of which was sent for chemical analysis. Both kidneys were of normal size, but the right kidney had a puncture wound surrounded by a contusion. The report of the autopsy indicated that the doctor punctured the right kidney during the operation without realizing.
A 34-year-old woman, para 2, was admitted for an elective caesarean section on 12 March 1998. The operation was straightforward and the immediate recovery period was uneventful. The patient died the same evening in the ward. The baby, who was delivered with severe meconium aspiration, died on the same day.
On autopsy, about 2 litres of fluid and clotted blood were found in the abdominal cavity. The uterus was empty, with just a few clots. The cause of death was found to be haemorrhagic shock. It appeared that the uterine sutures were not haemostatic enough, leading to continuing haemorrhage. There would have been enough time to intervene to save this patient if proper postoperative monitoring had been instituted and again it was a junior doctor who did the operation without an experienced supervision by a senior colleague.
Case of Miss A at Axum Hospital in Ethiopia
Background and Time line of the events in January 2006
Miss A 22 who had ANC follow up in nearby health centre, she had minimal bleeding in her 3rd trimester, the care provider in the ANC put her on iron tablet and advised her to deliver in hospital. In the mean time she developed severe vaginal bleeding. Brought her to a health centre 60 km away from her residence in the health centre they kept her for 24 hours before deciding to refer her to the next referral unit. On 02/02/2006 at 1.45 pm. admitted to St Mary's hospital Axum and she delivered dead foetus vaginally. After determination of Haematocrit, in the immediate postpartum period, the need for blood transfusion decided and at that time her Families were unfit to donate blood. As to the interviewed clinician there were delays in transfusing her at least for 24 hours, on 3rd February, 2006 at 2.00 pm. One unit of blood obtained but the mother died on 03/02/2006 at 5.00 am without being transfused.
Case of Miss D at Axum Hospital
Background information and Time line of events in January 2006
Miss D was admitted at St Mary's Hospital on 27th January, 2006 with history of retain second twin. She delivered the first twin who was stillbirth at home but the second twin was retained. The patient spent 2 hours at home before she came to the hospital for further management. On arrival her Blood pressure was 90/70 mmHg, with vaginal bleeding. An hour later, she delivered the retained dead foetus and went into shock. The doctor suspected uterine rupture, and immediately arranged for operation. But when the abdomen was opened, there was no rupture uterus, so the abdomen was closed. Later the nurses realized that the patient was not producing urine. The doctor went into the abdomen again and found that the patient was bleeding into the abdominal cavity. There was a great vessel that was cut during the operation but the doctor did not secure the vessel well to arrest haemorrhage. After securing the vessel, the abdomen was closed again but the patient died after 30-45 minutes. This is clearly wrong diagnosis, intervention and waste of time instead of carrying out the appropriate measures.
Case of Miss G at Korle-bu Teaching Hospital in Ghana
Background information and Time line of events in March 2011
A 26 year old patient was rushed in with eclamptic fits on the 18th March, 2011 with the help of her relatives. The doctors and the nurses acted promptly to resuscitate the patient but unfortunately the patient died after 30 minutes of implementation of the medical interventions. One of the consultants got furious because he claimed he saw and admitted the patient on the maternity third floor about 4 days ago with a provisional diagnosis of eminent eclampsia. According to the consultant, the patient's blood pressure was high (180/125mmHg) and so gave the patient medications and outlined some medical interventions that should be carried out by the nurses to control the B/P. He went to the ward in the evening to review the patient but was told that another doctor has discharged the patient. From the patient's document, it was clear that she had been mismanaged right from day one that she started seeking help at antenatal clinic and on the day of discharge, the B/P was 160/110mmHg.
Now the question is what prompted the doctor to discharge this patient with such a high B/P? The nurses on duty did not also inform the doctor about the high B/P, and they just took the orders without applying their critical thinking abilities. The worse of it all, they accepted discharging the patient without any documentation to show.
This action poses an ethical and a legal problem in care delivery. It was a case of negligence and a breach of duty of care. Both the doctor and the nurses, who discharged the patient, also violated the principle of not causing harm by their action. This situation could have been prevented if the patient had been assessed thoroughly before discharging from the ward. Knowing the condition of the patient, nurses should have created B/P chart for this patient and monitor the B/P consistently.
Conclusion and Recommendations
Maternal mortality is too high in most developing countries as a result of the multiple determinants that are socio-cultural, economic and health services factors. In spite of the fact that Emergency obstetric Care (EmoC) can prevent maternal deaths there are three delays to access EmoC that occur as a consequence of these factors, especially the aspect that involve failure of medical personnel to recognise the signs and symptoms to aid them diagnose and give appropriate treatment. These actions mostly lead to negligence of duty and the at times the life of the patient.
Although different strategies have been recommended to address maternal deaths, there continue to be an increase in number of women dying in child birth especially in south Asian countries and sub Saharan Africa. Strengthened efforts to simultaneously tackle all factors are required in order to reduce maternal deaths. The availability of Emergency obstetrics Care facilities without concurrently addressing the broad determinants of delays will not reduce maternal mortality. However, addressing these determinants requires collaboration of stake holders.
Again, women whose pregnancies are likely to be complicated by potentially serious underlying pre-existing medical or mental health conditions should be immediately referred to appropriate specialist centres of expertise where both care for their medical condition and their obstetric care can be optimised. Providers and commissioners should consider developing protocols to specify which medical conditions mandate at least a consultant review in early pregnancy.
In addition, all clinical staff must undertake regular, written, documented and audited training for the identification and initial management of serious obstetric conditions or emerging potential emergencies, such as pre-eclampsia, sepsis, which need to be distinguished from commonplace symptoms in pregnancy.
Furthermore, the management of pregnant or postpartum women who present with an acute severe illness, example sepsis with circulatory failure, pre-eclampsia/eclampsia with severe arterial hypertension and major haemorrhage, requires a team approach. Trainees in obstetrics and/or gynaecology must request help early from senior medical staff, including advice and help from anaesthetic and critical care services.