Why do mothers die in the hands of doctors?
Recent statistics from Statistics Botswana, indicate that in 2021, 240 women per 100 000 maternities lost their lives. This is in comparison to 126 to 166 deaths per 100 000 pregnancies between 2014 and 2020. With 99.8 percent of births happening in hospitals and clinics, this means that these mothers lose their lives in the hands of doctors.
It is on this backdrop that the Botswana Society of Obstetricians and Gynaecologists recently hosted its inaugural conference under the theme, 'Towards Quality Standardised Reproductive Healthcare in Botswana: Reducing Maternal Mortality and Morbidity,' at the Sir Ketumile Masire Teaching Hospital.
According to the Chairman of the association, Dr. Vincent Molelekwa, the congress is an important party of their profession and country as it seeks to address a chronic non-resolving problem in the form of a high maternal
mortality ratio.
Dr. Molelekwa, who is an Obstetrician, Gynaecologist, Mesotherapist, Endoscopic Surgeon, Fertility Specialist explains that the dialogue during the conference intended to find ways of standardising obstetric practice in the country, doing more of what they do better and re-looking at practices and standards that are no longer in vogue in ensuring good outcomes for both mothers and babies during pregnancy and delivery.
“Due to the importance of this matter to our profession and the country, the congress is a culmination of close coordination between the society and key stakeholders such as the Ministry of Health, the World Health Organisation and other important stakeholders in maternal health in the health sector,” he explains.
Giving a detailed outlook of what inspired the crucial conference, Dr Molelekwa explains that 95 percent of mothers dying during pregnancy and delivery are found in sub-Saharan Africa. In 2000 through the United Nations’ sustainable development goals (SDGs) program, Botswana set itself a target of 70 maternal deaths per 100 000 maternities. At that time the country was experiencing 262 deaths per 100 000 maternities.
“This trend has generally been going down such that in 2020 we had 130 deaths per 100 000, which rose to 240 per 100 000 in 2021 under the influence of COVID-19. The main issue is that although we have made some progress, it is way too slow a progress over 23 years,” he says.
On the other hand, he points out that Botswana was ranked third in the world together with other countries in terms of percentage of women delivered by skilled health personnel. In fact, Dr Molelekwa says that 99.8 percent of mothers delivered in clinics and hospitals in 2017.
From intuition, he shares that one would then expect Botswana to have one of the lowest maternal mortality ratios in the world as ‘our’ mothers deliver in ‘our’ hospitals.
“Yet that is not the case. Sadly, our mothers die in our hands, this reality is very heart breaking and it is the very reason why we are having this conference,” Dr Molelekwa says.
Painting the picture of how the landscape looks like in the Botswana context, pre-COVID-19 statistics shows that 78 percent of deaths happened during the pregnancy, while 22 percent died after termination of the pregnancy.
The 2021 COVID-19 statistics showed that 54 percent of our mothers died during pregnancy, while 44 percent died after the pregnancy stops.
“Of these deaths 61 percent happen in Gaborone and Francistown DHMTs, with Gaborone DHMT leading Francistown with 34 percent to 27 percent, respectively. These findings alone give us adequate idea as to where and how we need to intervene and the required resources to deploy to arrest the loss of all these precious lives.
“One of the ways to contain the problem is to focus our attention in Gaborone and Francistown DHMTs as these are the festering grounds for mortality. We need to ask from what conditions do our mothers die from, why they die from these conditions, what interventions need be put in place and monitor the effectiveness of these interventions,” he highlights.
Sharing the situation in the African continent, he points out that Mauritius, also delivered 99.8 percent of their mothers in hospitals and clinics in 2017, yet in the same year they lost 61 mothers per 100 000 maternities. Interestingly, Mauritius is ranked at the same economic level as Botswana and their mortality ratio ranged between 53 and 73 deaths per 100 000 over the 23 years.
“The society is looking at this disparity in performance between ourselves and countries at the same economic footing and we are asking ourselves why we have failed as a profession to discharge our obligations to the society. Our purpose is to seek long lasting solutions through dialogue captured in our scientific programme,” he highlights.
Unpacking the theme and its relevance, they opine that part of the reason that Botswana is doing badly in reducing maternal deaths is due to deficiencies in standardisation of obstetric practice in the country. Until recently, he says that Botswana did not train its own doctors.
“As obstetricians we are an inhomogeneous group in our training and standards, coming from different training jurisdictions to try and deliver a sound practice locally. Government through the ministry of health has done well over the years to standardise practice through issuing practice guidelines and equipping the health personnel especially in the public sector through the (EmONC) programme,” he points out. EmONC is Emergency obstetric and newborn care.
But to attain standardisation and maintain quality of service within the profession requires obstetricians, medical officers and midwives being regularly exposed to ongoing professional development and up-to-date practice literature, he explains. These, he says are lacking in the current setup.
Dr Molelekwa also points out that the aim of the congress is to equip practitioners with current practice standards in the care of women in their pregnancies looking specifically at the causes of maternal mortality in Botswana.
“We aim to deliver these objectives to our members and the public through academic intercourse with an international panel of experts. We hope to raise the practice bar and raise the standard of practice through our carefully weaved scientific programme,” Dr Molelekwa says.
The two-day conference looked at an array of topics that includes a scientific programme session where they started off by asking “why mothers die in Botswana” to help them look at local performance, and failures. They then asked, 'does early delivery confer any maternal and neonatal benefits in hypertensive disorders of pregnancy?'
“We asked these questions because according to the 2021 Botswana maternal mortality ratio, hypertensive disorders of pregnancy, in particular severe pre-eclampsia was the leading cause of direct maternal deaths in the country. One of the important recent discoveries is that early delivery improves outcomes for both mother and child. It is our hope that this should help in closing gaps in the management of pre-eclampsia and reduce deaths,” he highlights.
The conference also discussed controversies and current practice in vaginal birth after Caesarean section. He explains that one of the significant causes of maternal mortality was rupture of uterus during labour. A scarred uterus has an inherent point of weakness in its scar that can rupture during a trial of labour, according to him.
On the other hand, Dr Molelekwa notes that a woman has about 64 percent chance of delivering normally following a Caesarean section in which the cause is not repeatable.
“We also know that multiple repeat Caesarean sections is not a good thing for the mother as it predisposes to injury from adhesions and morbidly stuck placenta to its bed. The obstetrician has to make decisions as to which is the most suitable route of delivery for each mother in each scenario,” he explains.
Other topics in the menu included the management of ectopic pregnancy, an update and standardisation of prevention and treatment modalities in the management of severe haemorrhage after birth, how to help women survive overwhelming infections during and after pregnancy, and current practice in the conduct of assisted vaginal deliveries. All these topics address key areas identified as causes of maternal mortality in Botswana.
Dr Molelekwa also highlights that pre-COVID statistics indicated that 20 percent of mothers died after pregnancy terminates, that is within six weeks of the delivery.
“We asked if we can contain this problem through strengthening our primary health services. In this light, we asked whether there is a role of primary health care in the reduction of maternal mortality,” he notes.
To ensure uniformity and standardisation of practice, participants also had a chance to see and experience skills acquisition stations where folks would learn how to conduct safer vacuum deliveries, a new and easier way of managing shoulder dystocia (a stuck baby), using a sling technique - a practice that is not currently available in the country, how to effectively manage a breech delivery and effective ways to manage vaginal tears after delivery.