The three delays

Preventing maternal mortality and morbidity is often looked at using the three delays model, it is thought that reducing/ preventing these delays will substantially reduce maternal mortality.  These are  delay in seeking care, delay in transportation to healthcare facility and delay in receiving treatment at the facility. The 3 delays are all closely linked, and all need to be targeted to reduce maternal death and disability.

I've just finished a busy 24hr shift and two mothers stick in mind as perfect examples of this. 

The first mother was at a health center, she had been fully dilated at 9 am in the morning,  4 hours later they decided that she should have delivered by now and so referred her to us ( you can say that this is delay no.1- as it should take about an hour in those who have had babies before to deliver ), it then took a further 3 hours to transport her to us as there was no transport available.  So on arrival she was dehydrated, and was now fully for 7 hours!  When we listened to the babies heart is was beating very slow so we really needed to deliver fact.  The babies head was low and also showed signs that it had been there awhile, unfortunately it was in an awkward position  but we managed to do an instrumental delivery with difficulty.   Unfortunately the baby did not survive. 

The  second mother went into labour at home and delivered a baby at 11am without complications- however the placenta would not deliver and so eventually she went to a health center (3pm).  After assessment  they realised that she had twins (she had not attended antenatal visits so this was undetected) and the second baby was yet undelivered, on top of this the umbilical cord had prolapsed ( this is obstetric emergency as the pressure on the cord prevents oxygen reaching the baby causing fetal death- at this point the cord was still pulsating indicating the baby was alive.  ) And to prove bad things happen in threes she was also bleeding heavily as the first placenta was detaching, she was referred and reached us at 7pm- again transport being a problem.  It was clear at this point that she had lost a lot of blood, her clothes were soaked, her Bp was low and pulse high and we started resuscitating her with fluid.  Unfortunately the cord had now stopped pulsating, but luckily she was still fully dilated  and we could do a quick breech extraction to deliver the baby, followed by the placenta which settled her bleeding.   She still looks pale this morning but is doing well- it wouldn't have taken much more bleeding before the outcome would have been much worse.   So delay in self referral to a health center, delay in appropriate care- she did not receive fluids and no measures were taken with the cord prolapse, and delay in transport  caused a fetal death and could have caused another maternal mortality. 

Perinatal mortality

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Every morning we have a handover where the last 24 hrs statistics are reviewed for every ward and special cases discussed both as a learning point and also to help in patient management.  I am always surprised by the postnatal ward summary- it normally goes something like this:  on the postnatal ward we have 70 mothers 40 of whom have their babies with them.  My immediate thought is -what happened to the other 30 babies, they go on to say 15 babies are in the nursery/ nicu- and run threw the stats e.g 3 for birth asphyxia, 4 for prematurity etc. but there is still always a percentage unaccounted.  These are the babies that have died fresh still birth, macerated still birth and early neonatal deaths and its easy to see why these occur.

 It is too late to do anything about the macerated still births once they reach the hospital, the mum presents and already there is no fetal heartbeat detectable and hasn’t been for a few days, sometimes this is because of the distance the woman has to travel to reach the health facility by which point it is too late, but it is also due to poor patient education and the women not knowing to be vigilant for reduction or changes in fetal movements which could indicate problems and lack of attending for antenatal care so early problems aren’t detected and addressed . 

The bigger problem however and one that we can do something about are those babies who die within labour.  Imagine carrying your baby for 9 months coming to hospital, going through a long labour only to deliver a stillborn baby and be told that your baby has died- it must be heartbreaking!   The guidelines are that the fetal heart should be listened to every 30 minutes in the first stage of labour and every 15 minutes in the second stage of labour- this is often not feasible with the large patient load and staff shortages and sometimes the fetal heart is only listened to once or twice in labour, and so fetal distress is missed and poor outcomes common! 

If anyone has any suggestions as to how to improve this with limited resources please comment below.  I have been using the student to help, which has worked a little but they aren’t always around.  I also bought a CTG machine with me which I thought could be used for high risk patients after some training and excitedly tried to use it once but came to plug it in only to realise the sockets were broken and didn’t work. I also need to think of ways to motivate the midwives as i'm sure more can be done within the same system, it must be difficult when you are over worked and payed so little and poor outcomes are so common to not get complacent and just take it as the status quo especially as there are almost no repercussions. 

Malawi is actually doing quite well at reducing its child mortality rates but   neonatal mortality still makes up 32% of the under 5 deaths and may hinder in achieving the millennium development goals.   A high Perinatal death rate is actually an indicator for poor obstetric care within a country and this is clearly seen here. 

On deaths doors.

She came with abdominal pain and bleeding, drowsy but rousable and a pulse of 130 she wasn’t looking too good!   She was 37 weeks pregnant and all was going well till the day before when she started feeling dizzy then the pain and bleeding started- I kept asking her how she was feeling and all she could tell me over and over was – I am not fine, I am not fine!  She wasn’t bleeding too heavily anymore but unfortunately we couldn’t find the fetal heart beat and confirmed by uss that the baby had died.  When we did her blood test we found she had a Hb of 4! For the non-medics normal is above 10.  So it was obvious she had lost a lot of blood and was probably anaemic to begin with as most women are in Malawi.   Her abdomen felt hard and I thought she had an abruption- this is when the placenta starts separating and can lead to catastrophic life threatening bleeding.  Thankfully we know these women deliver quite quickly when labour is stimulated so we started resuscitating her with fluids and were lucky to get some blood which we stated giving her during the labour.  We were prepared for a Post partum haemorrhage, which is also common in these scenarios and managed it quickly and actively so as to limit the amount of blood loss, this could have all ended very differently had she delivered at home or not got to the hospital in time. 

This is why it’s so important to deliver in a health facility with doctors and midwives experienced in emergency obstetric care, without which this woman would have surely died.  I went to see her the next day and she told me with a smile- I am fine :)

Queen Elizabeth Hospital

I am working at queens, it is a big tertiary referral hospital, and they receive patients from all the surrounding districts.  The delivery rate is around 12, 000 per year the majority of whom are high risk - this is unheard of in the UK.  With this number of women the department still only has 3 consultants ( 2 are leaving soon :( ) , 3 registrars and 5 interns- newly qualified doctors.  There is also a shortage of midwives and nurses on the wards which are often flooded with patients,  because of this shortage patient care is often compromised and maternal and fetal death are no strangers here.  As well as clinical duties the department also has to teach the incoming medical students who are the doctors of the future- this is the main teaching hospital in the country. 

Malawi - background

Malawi is the one of the top 10 poorest country in the world with over 14 million inhabitants.  The people are densely populated in the south of the country.  Even though compared to its neighbours the health care is free it still has a poorly functioning health system and poor health statistics. 

Up until 1991 the was no medical college in Malawi, and there is still only one.  It has gradually grown from a program with an intake of 10-15 students per year and a handful of Malawian faculty, to a program with a medical student intake of on average 60 per year with 110 faculty members, of whom approximately 67% are Malawians. To date the college has graduated over 250 medical doctors. However it is said that there are more Malawian doctors in the UK than in Malawi and who can blame them given the poor pay and working conditions- the well known brain drain!   

There is still no post graduate training in Malawi for a lot of specialties and none for O&G although there is talk of this starting soon.   Currently  doctors have to go to  South Africa for their training further reducing the work force.

Clinical officers play a key role in the health services of many African countries. They can perform 60-80% of doctors’ tasks but are faster (3years) and less expensive to train.  Ammalife has looked at Six non-randomised controlled studies (16 018 women)  and evaluated the effectiveness of clinical officers carrying out caesarean section. Meta-analysis found no significant differences between the clinical officers and doctors for maternal death (odds ratio 1.46, 95% confidence interval 0.78 to 2.75; P=0.24) or for perinatal death (1.31, 0.87 to 1.95; P=0.19). Warwick University is currently working to train the clinical officers in Malawi and improve their training program long term as they carry out most of the clinical work particularly in the districts. 
Malawi has one of the worst doctor to patient ratios in the world. 

Maternal mortality is still among the highest in Africa - 71% of women are delivered by skilled
workers. The 2010 EmONC Assessment showed that only 2% of all the BEmONC sites and about 48% of the CEmONC sites are fully functional. Obstetric complications contribute significantly to maternal deaths and bleeding alone accounts for 40% of all deaths. Other indirect causes include delays in seeking care, poor referral system, and lack of appropriate drugs, equipment and staff capacity-  Maternal Mortality Rate is  675 per 100 000 (WHO 2010)

It is an exciting time in Malawi at the moment for maternal health with the new president making it a priority with her safe motherhood campaign- she has said that the goverment is determined that no mother should die while giving birth and of pregnancy complications. 
lets hope she keeps does not lose focus and that his is a start of great things- President Joyce Banda we wish you luck :)