Dying needlessly: Women and maternal mortality in Guyana
June 4, 2000
This is the first of at least two columns on women and maternal mortality in Guyana.
A newspaper report (SN, May 23) of an inquiry into the February, 2000 death of Nazeema Ibrahim, age nineteen, in childbirth, said, "every maternal death is followed by a series of investigations. This devolves from the principle that maternal deaths are avoidable. Investigations generally try to establish whether the patient benefited from maximum efforts to save her life."
Nice principle. But it is not true that every maternal death is followed by "a series of investigations". The Ministry of Health long ago instructed that every maternal death should be reported to the Chief Medical Officer within twenty-four hours, but whether the CMO hears about maternal deaths or not depends largely on how much rage is expressed and perhaps, acted on by the relatives of women who are victims of maternal mortality.
We must demand an independent inquiry into all maternal deaths. Like the death of 40 year old Halim Hoosain, wife of Mohamed, mother of six boys aged 5-16. Halim Hoosain of West Canje, Berbice, is reported to have died in the New Amsterdam Hospital on Saturday, May 13, just before 5 p.m., about half an hour after her husband had returned from running to the shop to buy Dettol for her use, or about an hour after he had returned from running home to get a pillow for her use - before which he had run home to get water for her use. A major government hospital in one of our "leading towns" without water, a pillow, a simple antiseptic.
Mrs Hoosain is reported to have been taken to hospital at midnight on Friday May 12, that is, early in the morning of Saturday May 13, bleeding and in pain. She was examined and admitted to the maternity ward. Less than 24 hours later, both she and the baby girl she delivered (the patients said they didn't hear the baby cry), were dead. According to the post mortem, the cause of death was a ruptured uterus and haemorrhagic shock. It had taken some time after her arrival at the hospital for a gynaecologist to be summoned. SN quoted a "medical source" (why don't they put their names?) as saying that Mrs Hoosain died not just from a rupture of the uterus, but from an undiagnosed rupture of the uterus. The public awaits the findings of an independent investigation to see whether she "benefited from maximum efforts to save her life".
The findings of the inquiry into the death of Nazeema Ibrahim, the 19 year old woman, show how little capable we are of "maximum effort". As the Guyana Chronicle and the Stabroek News of May 23, 2000 reported, the inquiry found that Nazeema Ibrahim's death was "avoidable". She died from post partum haemorrhage, or excessive bleeding after birth. The report made some telling recommendations: activation of the operating theatre in Ward 6 of the Georgetown Hospital; the presence of doctors on call in the room in Ward 5 available for them to stay in; a requirement that consultants respond when called by junior doctors; improved documentation; training of nurses to recognise when patients are in a critical condition.
My grandmother used to say, "I rest my case", meaning, "what you have said proves my point, not yours". In this case, the recommendations confirm just how bad things are. The hospital has been advised to implement them "with due despatch", with implementation monitored by the hospital inspectorate, who - no disrespect intended - should be monitored by the public. That is what would happen in a country where citizens felt entitled to an ordinary level of health care - like consultants responding when called by junior doctors.
Then there was "A", originally of Canal #2, who died (date not provided) at age 26 due to complications arising in her second pregnancy. When she was five months pregnant she started "passing water" and was told that her water bag was broken and she needed an abortion. Taken to a private hospital, she was prescribed a nine day course of treatment and bedrest. Two days later, she was discharged although bleeding. Taken to a private clinic, she was given an ultrasound and advised to take a week's bedrest. A few days later, with pain in her belly, she was rushed to Best Hospital and admitted. Two days later she was bleeding and in pain, but was not seen by a doctor. The next day the mother learned that she had vomited all night. Some time the same day the doctor said that the foetus had died, and she needed two pints of blood to be operated on the next day. The vomiting continued; she passed the foetus in a toilet; a nurse was paid G$2000 to help take it out of the bowl; the doctor came and apparently tried to remove the afterbirth; the patient was given saline but no blood (relatives were told that blood they had given in Georgetown "hadn't reached yet"); it was decided to send "A" to the Georgetown Hospital but there was no ambulance; when the ambulance came, "A" started on the journey to Georgetown but died on the Demerara Harbour Bridge.
The inquiry report on Nazeema Ibrahim said, "All obstetric deaths are avoidable, and with diligent care, teamwork and prompt action, this could be achieved."
In August 1998 "S" gave birth to a girl who died; S died two weeks later. When she began feeling ill she was taken to the Vreed-en-Hoop hospital at about 4 p.m., admitted and given saline. The doctor came at 8 p.m., just as S was dying. She is said to have died of a pulmonary infarction.
In 1996 37 year old "C" was admitted to the New Amsterdam hospital for labour to be induced. There were complications with delivery, so she was taken into theatre for a caesarian. That was at 11.15 a.m. She bled internally, they removed her womb, the bleeding continued. At 1 p.m. her husband was sent out to buy drugs and saline. She was taken into theatre again at 1.15 p.m. and 3.30 p.m. After she returned to the ward she was still bleeding and her heartbeat was irregular. Later that night the hospital said her blood pressure had stabilised. The next day, early, her husband was sent to Fort Wellington Hospital to get drugs; by the time he returned to New Amsterdam it was midday. When he was told his wife needed blood, he went to give blood, but there was no technician. "C" died of postpartum haemorrhage.
The last official rate of maternal mortality in Guyana was 125.7 per 100,000, in 1998. That is a decrease from the previous figure. However, the Guyana rate is high compared with those of other countries in CARICOM, for example, in Jamaica the rate is 100, in Trinidad and Tobago 75, and in Barbados, 50. What is worse is that it is hard to find any informed person, in or out of the Ministry of Health, who does not privately admit that the figure is wrong. We have no specific way in writing death certificates of attributing death to maternal causes. A maternal death is any death attributable to pregnancy, not just delivery. It can occur up to six months after delivery. A month after delivery, women can have conditions directly related to the birth of a child, yet the cause of death on the certificate does not take the birth into account.
Why are our rates high? Dr Cummings, Chief Medical Officer says that how much money a country has will help determine how many maternal deaths it has. Once you reach a certain threshold of national income (though this is not true in the US, because of income disparities), maternal deaths become almost non-existent. Maternal mortality is a disease of poor women in poor countries." So our national poverty is one reason our maternal mortality is high. But there are other reasons. For the 20th century, one expert told me, our post delivery evaluation is not where it should be. Second, when there are post-delivery complications, the patient must be seen by someone with experience; this does not happen. And third, professionals must be motivated that on their watch, patients don't suffer or die needlessly; we have not reached anywhere near there. All this, the person added, is worse in the public sector than in the private, since the private sector has to compete for clients.
And so, too many pregnant women in Guyana suffer and die, needlessly.
Follow the goings-on in Guyana
in Guyana Today