Mothers will not stop dying from preventable causes until we address quality of care

There are some stories that read like a good novel. Only that these stories end in tragedy. And even worse, these stories are not fiction, but reality.

Last week, as a group of gynaecologists taking a long hard look in the mirror, we not only shared heartbreaking stories of lives needlessly lost or maimed due to highly preventable causes; but also renewed our commitment to preventing maternal and neonatal morbidity and mortality. This is our commitment to achieving SDG 3 in our little corner. The conversations took me back to the hair-raising account of events I had to audit a few years back that left me broken for weeks. Catherine* was only 24 when she got pregnant with her first baby. She was recently married and was looking forward to the new addition in the family.

She attended her antenatal clinic at the local dispensary. where all was well. As she approached her due date, the couple settled on delivery at a private maternity home that was not too far from home. Catherine went into labour in the early hours of the morning and her husband took her to the hospital by 6.30am.

The midwife who received Catherine was very pleasant despite being at the tail end of her night shift. She quickly settled Catherine in bed while her husband Jackson* went about processing her admission and ensuring that all was in order, in line with their “Linda Mama” benefits package that ensured mothers got access to free maternity services in Kenya for the past decade.

When Jackson got back to the ward, the nurse reassured him that Catherine was still in early labour and it would likely be nightfall by the time the baby came. She sent him away and told him to check in during the visiting hours. Catherine was already having porridge served by an efficient attendant and she seemed comfortable.

When Catherine was reviewed at about 10am, the clinician found that labour had progressed but she still had a long way to go. He encouraged her to walk around the ward to help with the descent of the baby’s head into the pelvis.

Six hours later, Catherine had made good progress and the clinician gave her hope that the baby would arrive in another two hours. Jackson was already back at the hospital, ready to meet his newborn.

At about 8pm, Jackson was anxiously pacing outside the ward waiting for news of his baby’s arrival. Instead, he was informed that there had been no further progress in labour and a caesarian section was needed to deliver the baby. Jackson assented to the surgery in order to ensure his wife and baby’s safety. He walked beside Catherine’s wheelchair as she was wheeled to theatre, and bid her farewell, promising to see her in a few hours.

An hour later, the nurse who had escorted Catherine into the theatre peeked out of the theatre door and informed Jackson that the caesarian section had gone smoothly and they had discovered that the baby was too big for Catherine to deliver him normally. He weighed a whooping 4,480g!

Jackson was reassured that Catherine was doing well and the surgery was coming to a close shortly. He was also informed that Catherine would remain in theatre for monitoring for at least two hours before she could be transferred to the ward. With this reassurance, Jackson stepped away from the theatre entrance and went to call their family with the good news.

He even got a cup of tea from the little shop outside the hospital to keep him warm as he waited for his wife. He went back to the theatre door to ask for an update and the nurse told him that Catherine had bled a bit, but she was fine. The doctor had finished the surgery and Catherine was at the recovery unit, drowsy but stable. Further, he was informed that the doctor had asked that she remained in theatre all night, for continuous monitoring, as a result of the heavier than usual bleeding.

Jackson was given a change of shoes and a gown to allow him to tip toe into the theatre recovery area to check on his wife and meet his son. He was then asked to go home and get some rest. The jolly nurse took the baby back to the labour ward, to the little makeshift newborn unit, to be kept warm and watched over while waiting for mum.

The theatre nurse who was left behind had one job and one job only. To monitor Catherine’s vital signs. She did an exemplary job of it. She kept a neat chart of the pulse rate and blood pressure every 30 minutes. For five hours, she documented these readings into oblivion.

Catherine complained of feeling cold, then nauseous. The nurse added extra blankets and brought her a bowl, just in case she actually vomited. She recorded a pulse rate that consistently increased, up from the 80s to 150 beats per minute. She concurrently recorded a consistently dropping blood pressure until it was almost unrecordable.

This read like a movie. The nurse was completely oblivious to the reason why she was monitoring these parameters. This extremely critical monitoring that gives us an early warning that things are going wrong, was completely missed. It is only when blood started dripping down the bedside that she got alarmed and called for help.

As expected, there was absolute pandemonium. The patient had already lost so much blood, she was in shock. Efforts to resuscitate her were in vain. At some point someone called Jackson, who arrived just as Catherine was being loaded onto an ambulance for referral to a bigger hospital with better access to blood, blood products and a larger and better equipped team to help. Jackson lost his wife in the dead of the night, in an ambulance, at the parking lot of the hospital.

During interview, the said nurse was scared out of her wits. It was clear that though she had attended the requisite training in nursing, managed to pass her examinations and get a practice licence, she grossly lacked situational awareness and basic knowledge translation into practice. She could not interpret the meaning of the vital signs decline.

The hospital was also culpable. There was failure of the part of the team to expressly recognise that Catherine was already a high-risk patient for severe postpartum haemorrhage as she had delivered a large baby. There were no preventive measures taken to shield Catherine from the anticipated complication.

To top it all off, this young and inexperienced nurse was scheduled to work alone in a high-risk space, without oversight. Even worse was that this was a small maternity home with a low turnover, hence skills and experience development was going to take time. This should never have happened. Mothers will not stop dying of preventable deaths until we address the little weighty matter called quality. Quality of the healthcare staff training and experience-development; quality of drugs and non-pharmaceutical products in use; and finally, quality of systems in place, to ensure early detection of complications and appropriate triggers and responses for correct and timely intervention. Let’s stop tearing families apart needlessly!

Dr Bosire is an obstetrician/ gynaecologist