Maternal mortality : the importance of time.

So we have spent the last few posts talking about maternal deaths and their different causes, different shortfalls in our health seeking attitudes, lapses in health care system etc. There remains a vital aspect we are yet to discuss. .. the concept of ‘estimated time interval’.

This estimated time interval is the average time it takes a particular obstetric emergency to go from onset to death ( in other words, the length of its natural history.) This knowledge is priceless. It helps us understand the impact of the various delays we encounter . 

The following are some of the emergencies and their time intervals.

1. Haemorrhage :

      a) antepartum haemorrhage has a natural history length of 12 hours

      b) postpartum Haemorrhage a time interval of 2 hours

2. Ruptured uterus: 24 hours

3. Eclampsia: 2 days

4. Obstructed labour: 3 days

5. Sepsis:  6 days

Worth mentioning that these time intervals are recorded for emergencies that have an easily identifiable starting point. Hence things like ectopic pregnancy or pulmonary embolism don’t feature in our list above.
So the above goes to show that ‘when’ a patient shows up at the hospital largely contributes to determine the outcome.  It is not enough to strike yourself on the chest and claim you did your best by bringing your spouse to the hospital (sometimes  after exhausting other avenues) rather we should endeavour to seek treatment on time. Help doctors help you.

That is the end of my maternal mortality series. Hope you enjoyed it.

For those that are interested in knowing the end of the two stories abovery lemme briefly summarize.

Mrs A, was treated in the hospital. She was sectioned and after 2 weeks in the hospital she was discharged with her beautiful baby. She will be taking her baby to church on Sunday. 

Mrs C, was rushed into the theater for a hysterectomy (due to uterine atony). She is fine now. She was unable to breastfeed after delivery so is formula feeding her baby. She is doing great. Mr C reported the dealings of the receptionists to the director and  the security man and Nneka were fired. The director has invited one of the missionary doctors in the village to come and teach all members of staff basic life support this friday. 

Yes… they were all made up stories and since I had the powere,  I made them all happy endings. A future health care system that would be full of happy endings is what I wish for my country… no! Rather what I strive to see achieved in my country. 

#ourhealthisourwealth.

THE END

Maternal mortality : Level 4 delays

Act 2 scene 2: Mrs C has finally been taken to hospital by her husband. They arrive at the health centre 

Mr C: (at the gate) oga please help me. My wife just fainted while going to ease herself. Where can I take her.

Gateman: ( a bit irritated) oga carry am go inside hospital.

Mr C: please which side, this is my first time here

Gateman: ( laughs), I no be doctor ooo. I no sabi which side you go go. Just enter inside and ask them.

He drives into the hospital compound. Leaves his wife with his first daughter in the tricycle car. He rushes to the security man at the door of the complex.

Mr C: oga, please help me. My wife needs to see a doctor.

Security man: sir, is this your first time here? Go to that counter over there where people gathered, they will attend to you.

Mr C: with all those people there? But this is an emergency na..

Security man: ( whispers).. oga when you reach there, tell them you want to buy emergency card. It will cost you ooo. Just ask for Nneka, she will atend to you.

Mr C moves towards the reception counter. He tries to make his way to the front of the line.

Patient 1: oga, where are you going to? Since I have been waiting, you that just came now you want to jump line.

Mr C: I want to buy emergency card 

Patient 1 : me too. 

Mr C: ( puzzled ) but you look fine.

Patient 1: you too. Me I want to be attended to sharp sharp, that’s why I am buying emergency card.

Mr C: so you mean all these people on this line are buying emergency cards?

Patient 2: yes ooo.. abeg just go to the back of the line.

Mr C is roughly pushed to the back of the line. He stares hopelessly at the crowd. He is lost in thought when he hears a familiar voice.

Mrs D: Papa Nkechi (she calls out). What brings you here? How is mama Nkechi?  Has she put to bed?

Mr C: Thank God, please , my wife is outside in the keke, she fainted after delivery, I have been standing here, please help me, please , my wife, …

Mrs D: calm down oga, where is she? ( He gestures towards the car park) Take me to her. Okeke tell Okafor to bring a stretcher and come with him now now ( she calls out to a porter).

In the tricycle car, Mrs D does a quick assessment, and gives the following instructions.

Mrs D: Okafor,  take this woman to the emergency room, tell them to call the doctor immediately. Okeke, collect this man’s money go and buy card for him. Papa Nkechi let’s follow to the emergency ward.
There are soo many things amiss in the dialogue above, soo many time wasting activities. We can gather the following from the above

1. The man could have been directed straight to the emergency room by the Gateman or the security man

2. The misuse of emergency cards which serve atimes as bribes patients pay in order to be seen first by the doctor.

3. The undeniable fact that quick attention is given to those that have relatives or friends in the health care system ( a sort of man know man situation).
You guessed it, level 4 delay is a delay in receiving appropriate care. It includes cumbersome hospital protocols, inadequate manpower and sometimes reduced financial abilities of the patient. It is factor in 52 percent of maternal deaths. 

Everyone knows that the process / time involved before seeing the doctor can be pretty frustrating. First you come to hospital, they are doing praise and worship at 8am ( this is ok, if there us a specified time for it and it is made clear to everyone), worship is over, to get card- stress ( the crowd, the rude receptionist, the perpetual search for change). You finally fill out your biodata. Then you wait for an eternity for your card to get to the nurses station. When it gets there, you again have to wait because the nurses are on ward round/handover. Suddenly, a nurse saunters in and places a new folder at the top of the pile while you look on helplessly. Finally after almost 4 hours of waiting, you finally get to see the doctor, you are angry and you snap at the doctor who can’t understand your reason for being antagonistic.  See the stress of going to see a doctor can even kill some people faster than their ailment.

At this point I would like to admit that not all hospitals are like the above. Some private hospitals have adopted specific consulting times, some use the appointment based structure etc. But for the majority the above is what can be expected.

Before you rush off to comment on all your bad experiences in the hospital let me put some points across to you.

1. Hospitals are not NGO’s . Their workers are not volunteers. They have expenses that must be paid, taxes, salaries, renovations and not to forget profit needs to be made.

2. Health care is expensive everywhere and somebody always has to pick the tab… govt? Insurance? Or individuals. . By paying your bills,  you empower the hospital to do 1 above. Even in NGO’s, the tab is picked up by donations of philanthropists. 

3. When a hospital cannot afford to pay it’s bills, staff power becomes stretched too thin, financial renumeration is no longer commensurate to work expected, staff unsatisfied and distracted because of the need for extra source of income.

True, we have a long way to go in our health facilities and a lot to do as health care workers, bringing all involved together is a necessary step. Time we all joined our hands together and abandoned this internal fight for supremacy. The health care system can only be as strong as it’s weakest link. This rivalry is our undoing. Are you a nurse? Be the best nurse the centre has seen, are you a cleaner? Let the others exclaim that there has never been a better cleaner than you. Are you a doctor? Deflate your ego a bit and give respect where due. For our centres to operate at max levels, we NEED all the various professions. #stoptherivalry #weareallimportant.

 On a final note, when eventually we begin to get middle/low class appointment based consultations, please note that if you miss your appointment, you will have to reschedule… time is money. #africantimedoesnotapply 


Maternal mortality : Level 3 delays. 

Act 1: scene 2. ( It has been a week since the discussion between Mrs A and Mrs B, Mrs A has collapsed during their women’s meeting)

Mrs D: .. (panicking).. presido,  please this meeting can wait oo.. Agwo no n’akirika.. Pls don’t gather around her.

Presido:  does anybody have her husbands number?

Mrs B: yes I do. Here it is. 

Presido: ( tries the number on her GSM ).. service is poor.. it is not connecting.. is her house far from here? Let us send some children to her house to inform her relatives.

Mrs B: no need ooo, nobody will be home by this time. Her husband is working in town and only comes home on weekends. But I know she goes for antenatal at the health centre in the neighbouring village.

Mrs D: they will just turn her back.. their doctor doesn’t come on Thursdays. . It is better we send her to the local government health centre.

Presido: (raising her voice)… quiet everyone. Mrs A needs to be taken to the hospital immediately. Does anyone have a car?

(Several murmurs).

Mrs E: my husband is a commercial driver, let me call him, am sure he will come. Mrs A is my very good customer. . It is a pity what has happened to her..(Leaves to make a call)..

(Meanwhile two women in an aside conversation )

Mrs F: (whispers).. I knew it. See how she was swelling like balloon. Was she not even going for antenatal? All these small girls that think antenatal is only to go and eat okpa and fried liver, they will be sleeping during lecture but time to jump, they will jump pass chioma ajunwa.

Mrs G: ehnnn. . But I heard she drank coke after taking her routine drugs. Are you not sure that’s why she fainted?

Mrs F : it’s true ooo.. shebi health centre used to give vitamin C with routine drugs.. (hisses) mtschew. .. have you seen.. Agwa nti nti anughi,egburu isI nti esoro. 

Mrs G : anyway, God should save her shaa.. 

(Mrs E is back and is not looking happy)

Mrs E: (sadly) my husband said he went for outside job and that all the motorists he called refused to go to that area because of the condition of the roads. I am sorry.

Presido: no problem,  you have tried. Anyway while you were outside , I called pastor/revered/father and he is on his way. He will take her. However let us all say a prayer for her while we wait. Mrs B pls continue trying her husbands number so you can inform him about what has happened. 

The End.
So, the women above have correctly identified the need for medical care, identified the appropriate place to go yet they still get delayed because of the state of the roads. This one I call government -associated delays. You know where to go, but you don’t know how to get from point A to B. 

I hope you took note of my special aside between Mrs G and Mrs F. I put it there not because I wanted to highlight the level of gossip at women meetings rather to highlight common errors people make.

  • First. .. people will ALWAYS gossip about others especially during bad scenarios. 
  • People with little information tend to blame the victims
  • People jump into conclusions without an inkling of the facts surrounding a situation.

So before you start speculating and sending erroneous messages, try to get the full story.

Delay 3 is a delay in reaching appropriate care. It is caused by bad road networks, unequal distribution of resources , lack of emergency transportation (in our environment). It is a factor in 19 % of maternal deaths.

There is no flip side in this delay oo.. it sits squarely  ( and I must state prettily)on the heads of the GOVERNMENT. 

Maternal mortality : Level 2 delay

Act 2 scene 1: ( Mrs C has just given birth( it is her 7th child) at home assisted by the local birth attendant (TBA))

Mrs C: mama ejima, this one blood is comin out like this? I am feeling weak oooo. It has never been like this oo. I have just eaten eba still my eye is turning me.

TBA: Madam, you are supposed to bleed na. Why are you behaving like a JJC?

Mrs C: I know oo, but this bleeding is too much. See how blocks of blood are coming out… won’t my blood finish? Should I go to the health centre so they can check? 

TBA: hmm… Madam,  I have been helping women deliver long that health centre doctor was born. Some people bleed more than others. This your bleeding will stop. Ask mama Nkechi, her own stopped. Or did you not hear about mama Ada that went there and had to pay huge sums of money?

Mrs C : but I am worried oo.. 

TBA: (shakes her head). Have you forgotten that it is a taboo for a man who is not your husband to see your nakedness. 

Mrs C: I know mama ejima, but I don’t want to die like Mazi Okeke’s wife did. If I die, who will take care of my 7 children? 

TBA: Ok ooo… you can go and waste your money there. Just pay me my money before you go.

The End
In the scene above we have a lady who has appropriately identified a possible problem. Yet she still has some challenges to overcome before she goes seeking appropriate help. They include:

1) a discouraging environment… the TBA is discouraging the woman from seeking adequate care. Maybe because she truly thinks the issue is not critical. Or it could be as a result of pride.

2) the woman is hindered from visiting the doctor because he is male and this poses a problem in the light of local traditions.

3) once again, the doctors age is an issue… translates to lack of trust in the abilities of the doctor.

4) although not directly mentioned, money seems to be an issue too.
Level 2 delays are delays in seeking care. If delay 1 is caused by ignorance, delay 2 is caused by a deviation from expected behaviour due to cultural, religious beliefs and socioeconomic status. This delay is a factor in 40 percent of maternal delay.

So our dear mums-to-be, always exercise caution while seeking health advice. Some people may have the right intentions yet give the wrongest (had to use the word)advice. If at any point, you have that underlying nagging feeling that something is wrong, don’t hesitate to seek medical opinion. Better safe than sorry.

Applying this to other health incidents… Mr self medication, you feel ill and you rush off to the chemist. Even though you have sought ‘health care’,chances are you may have denied yourself the opportunity to seek appropriate care (I know a good number of times antimalarials offer solutions).

On the other side of the coin exists a very unique sort of delay 2. This delay occurs as a result of corridor consultations.. yes I said it.  Asking for over the phoneymoon prescriptions can actually delay you from getting appropriate care. So the next time your doctor relative insists you go to the nearest hospital instead of prescribing over the phone, it is not because she is itiboribor /olodo rather it is because some cases are better physically assessed.

This is one delay where ‘change really begins with you’.  Okwu agwugo.

​The demise of our health care system #5

. We have failed the health care system at the individual level. 

Some people will argue, they are not politicians, the do not work in ministry of health, they are not health workers, so how can they partake in the responsibility of sustaining our health care system. 

Have you considered that your health seeking behaviour is a MAJOR determinant in the succes/failure of health goals?  Lemmie explain further..  1. Baby has fever and you have been giving her paracetamol for 4days with no improvement…  Suddenly she starts to convulse on a Sunday morning and you rush her to the hospital. You get enraged that the doctor is not around to attend to you immediately, baby dies and you come to social media blasting the hospital and threatening to sue the hospital for negligence…  

2. Baby falls and sustains a green stick fracture and you take her to your local bone setter who ties off all circulation to the poor hand and you believe that the tighter the splint, the quicker it will heal. Baby’s hand changes color and it dawns on you that some people actually studied to treat such cases and you bring baby to hospital. Baby has to have an amputation as hand is dead and you go around town gossiping that Dr A too dey cut cut leg and hand. 

3. Oga at the top of the house… Madam cannot go to hospital till she gets your signed and approved consent. You are a very rich man, yet if any of your family members sustains an injury when you are out of town, na so so beg beg madam will be doing. 

4. Mr D, every ailment you have is not your portion. First You live in denial of your ailments, then you try different manner of homeopathic solutions and when all fails you drag your complications behind you like luggage to the hospital, Dr B doesn’t know which one again to treat, your original illness? It’s complications or complications of your self medication. 

5. Mr M,  you are always quick to demand the doctor be at your Beck and call. Lamenting about how you had to wait for 3 hours before seeing the doctor, yet when medical bill comes, you will fight tooth and nail to make sure you don’t pay the complete bill. 

6. Mr B,  you are not like the above,  you patronize the best hospital,  pay all your debts. Yet when ebola crisis hit, you jacked up price of hand sanitizer to make money. Have you wondered why developed countries spend so much money on control of communicable diseases half way around the world? It is because they understand that an epidemic miles away if not controlled can become a pandemic at which point control would be next to impossible. So that lady, you refused to sell sanitizer to out of greed,  is your son’s kindergarten teacher. If she gets sick chances are so will your son and maybe you in turn. There is money to be made in the health sector but not to the point of sheer exploitation. 

7. Madam H.  You are a food vendor with little kids..  You wipe baby’s but and quickly serve your customers without washing your hands. 
I can go on and on and on, but I am tired and want to rest. 

The above maybe extreme cases, the truth is we all have a part to play while we wait for favourable health policies.

​The demise of our health care system #4

We have failed our system at the level of our religious leaders. 

I am not for or against any religion( it is up to God to judge not me) or denomination. 

I believe in everyday miracles

I believe God is capable of any and everything. 

I also believe that God is omnipresent, hence I do not have to be physically present to receive God’s miracle. 

My focus point happens to be religious leaders who allow their followers to come and deliver in church without any form of QUALIFIED health worker present and then quickly ship the patient to the hospital when things go wrong. Why must the patient be within your premises? Is God’s ability limited to your church compound? I believe you can be praying at your church while patient is in the hospital, after all Jesus didn’t need to go to the home of the centurion to heal his servant. 

In school we had a popular slogan ” read as though it depends on you and pray as though it depends on God (which it does)”.  Why can’t we adapt it in life. Seek medical attention as though it depends on doctors and pray because it depends on God “.

​The demise of our health care system #3. 

We have failed our system at the level of the health care workers. 

This section doesn’t need much introduction ( the numerous strikes and disagreements say it all) 

A DIVIDED HOUSE CAN NEVER STAND. 

To all health care workers…  doctors , nurses, , pharmacists , lab scientists , physiotherapists, psychologists, community health extension workers(CHEWs),  traditional birth attendants. We are all after  one thing (and it isn’t money).. Patients health..  Even if we are not moved by empathy for the sick patient, nobody wants to be called a murderer. That said. This ‘us’ vs ‘them’ attitude is killing our system. Everybody wants equality in benefits, nobody considers equality in responsibility, or equality in working conditions. Just as in the human body, the heart and brains work even when the rest of the body is asleep(responsible for keeping the body alive) , the leg cannot come and complain that it is not given as much respect as those parts. 

It is even in the Bible.. 1 Corinthians 12 vs 15-22 

.. …… 17 If the whole body were an eye, how could it hear? If the whole body were an ear, how could it smell?………

21 The eye can’t say to the hand, “I don’t need you!” The head can’t say to the feet, “I don’t need you. 

We need each other to function at maximum level. Our goal is good patient outcome and quality of life. Everybody has a job to do, each important in its own right. 

As for our alternative medicine colleagues…  I cannot delve into what I don’t know. Please we need clinical trials for your various remedies.

​The demise of our health care system #2

We have failed our health care system at the state and local government level. 

It pains me when I go to the market and see insecticide treated nets (ITN) boldly written NOT FOR SALE still being sold at normal prize. Are those not nets meant for distribution to pregnant women as part of the roll back malaria project? Or is it seeing same nets being used as potent rat exterminators at the back rooms where they have been abandoned? 

I must admit that in the area of vaccination… There is some semblance of law and order. But why can this not be applied to all other aspects of health care. 

All our traditional birth attendants, who supervises them? Who updates their practice periodically? 

What about a state ambulance system? Why do we not have emergency response teams who can be called upon to rush citizens to the hospital when necessary? 

Why can’t we have state sponsored free medical consultation for at risk groups such as children under 5yrs, pregnant women and above 65yr olds?

Why can’t we have states sponsor regional  health demographics? 

At this point, may I remind us that the health system affects and is affected by other systems in the environment..  Thus if the ministry of agriculture comes up with innovations that improve food security, it will go a long way to reduce Malnutrition( a health problem). So before you go dancing and shouting that you are not one of ‘them doing nothing in ministry of health’ ask yourself is my activity /inactivity promoting/ destroying the health care system.

​The demise of our health care system #1

 
Our health care system is dying… 

Who should we blame? 

The doctor? 

The nurse? 

The politician? 

I should be blamed 

You should be blamed

We all should be blamed. 

Good health is an extension of our innate desire to survive. It is a primal need regardless of one’s socioeconomic background. It concerns the big guy in his penthouse suite and the native in his remote village who has never seen electricity or watched a television (where such exist). 

We complain everyday that our health care system has failed us when in reality,  we have failed our health care system and in turn failed ourselves. 
We have failed our system at the federal level, where we spend billions on programs( which are good) to enrich the health of citizens without any follow through. It is a shame that none of these programs ever attain a level of self sustenance.. Such programs become money sinking projects which are quickly discarded the moment power changes hand. 

At this stage we should be hearing more about NIMR and it’s impact in the media. 

Sending samples overseas for laboratory tests should be a thing of the past..  We have the brains who simply require the financial backing. We must therefore strive for projects that have the capacity of becoming self sustaining so we can free up the money for other ground breaking innovations.

​TIME TO STOP THIS  ‘DELIVER LIKE THE HEBREW WOMEN’ FALLACY. 

A friend of mine, Onyinyechi Njoku, recently wrote a post on women loosing their babies and even lives following decisions not to undergo cesarean section with the sole reason of wanting to ‘DELIVER LIKE THE HEBREW WOMEN’ of the Bible. 

There are two points raised in this popular belief/argument . 

1. The Hebrew women were said to have delivered without the assistance of the midwives

2. Cesarean sections are not mentioned, hence the Hebrew women all had vaginal deliveries and cesarean sections are not biblical. 

As a Doctor, nothing enrages me as much as people shaming mothers who have undergone c/s. 
1. See,  the truth is this…  The whole “deliver like a Hebrew women” movement is based on a LIE that was told by two women many millennia ago. 

Yes…  I said it…  The midwives lied!!  AND THEY WERE BLESSED FOR IT. 

Before you start quoting Bible for me, please go and re-read that chapter.. 

Exodus 1..

vs 17:….. But the midwives feared God and did not as the king of Egypt commanded them, but saved the men children alive. 

vs 19….. And the midwives said unto pharaoh,………….  for they are lively and are delivered ere the midwives come in unto them. 

vs 21:….. And it came to pass, because the midwives feared God, that he made them houses

So the argument really is based on a false premise.
2. A lot of people would probably argue that Moses was born in the house without any assistance from midwives (this is the only way his birth was not detected), however…  No mention is made in the Bible if his mother was assisted by a midwife or not. And no mention was made of what his parents must have told the neighbors about his birth… (maybe they told them that the baby had died,  or his mother had a really small stomach).. But this argument also doesn’t hold much sway as a reason to reject c/s because we all have heard stories of /even witnessed women deliver at unusual places.. Eg cars, market place, etc all safely with little or no assistance… This is a variation of the normal.. Fact is, some people have labour easier than others..it is not a function of religion or belief..  Maybe belief might increase positive thinking which may improve outcome but that is a whole different argument. 
3. It is not surprising that c/s is not in the Bible (I have not seen, if you have pls correct me), so also is transplant not there or radiotherapy or other modern medical procedures. However..  One undeniable fact is this….  The Bible hardly mentions cases of women dying during childbirth or infants dying, I wasn’t there years ago so I can’t give facts..  However it is very common practice to forget /not talk about stillbirths or infant births while recording family history, hence we can extrapolate that same rule may have also been  applied in writing the Bible.. 
Granted, majority of pregnancies can result in safe delivery even without medical intervention, nobody can guarantee 100% which pregnancy will require intervention or not.. Not even a ‘Hebrew like’ previous delivery can guarantee that. The doctor can only  tell you those at risk

God is a God of miracles.  Doesn’t mean you should kill yourself by yourself. 

Pls let us stop deceiving our women and DEFINITELY stop making those who have undergone c/s feel inferior. 

Remember ‘once a c/s always a c/s’ is not true for everyone, neither is ‘once vaginal always vaginal’. 

#strengthnotmeasuredbymethod