No Woman Should Die While Giving Life - Impact of Maternal and Child Mortality on Families

I was mapping innovations in maternal and child health while working as an independent consultant. In a span of one week, I witnessed all possible outcomes of a child's delivery. In one case, a first-time dad lost his wife immediately after she gave birth to twin boys. He was devastated and refused to hold the infants. He cried over and over that they had killed his wife. He lamented that if he knew the outcome of wanting to be a dad would kill his wife; he would have chosen to remain childless. Eventually, his mother took the little ones home. To date, I wonder about the lives of those little boys and the stigma they faced from birth.

In another case, the child died but the mother survived. The parents blamed themselves for the loss. Yet in another episode, both mother and child died immediately after delivery due to unforeseen complications. The husband was inconsolable. The medical staff were also impacted. The hospital was shrouded in subdued sadness over the loss of lives despite all efforts to save mothers and their newborn babies. Hospital cleaners huddled in a corner condoling with the families in silence.

As an innovator, I was affected too by these negative outcomes. I had joked with the mother of twins about being a pilot subject for a project and the next thing, she was gone. I was thinking, just like that? This was supposed to be a joyous moment.

On occasions where there was a positive outcome for mother and child, the celebration was rapturous for family members and the medical staff. Prayers would be said in abundance. Some new grandmothers would start competing on who resembled the child and what names should be assigned. Fortunately, more cases were positive than negative, but when the negative ones happened, they hit hard.

So how did I end up spending lots of time in public and private medical facilities in an East African country and interacting with some medical departments and divisions in the Ministry of Health?

I was supporting a series of partners in mapping telemedicine opportunities including leveraging mobile phone technology in maternal and child care, non-communicable diseases, disease surveillance etc . I realised for a solution to land, I had to work closely with the medical fraternity for ownership but also to understand their needs, develop system requirements/specs and ensure the tech that was being designed was relevant.

I reached out to the Director, MOH, and after persisting for a meeting, I was eventually given a 7 am appointment on a Monday. He kept time. But just before my appointment, he had another one with a foreign government, from 6am, that invested over 300M USD on a health initiative. I come along empty-handed with ideas. Not even a dime to pay the per diems that would get government staff to the field.

I pitched the ideas and then said I had no money but intended to work closely with his team to make the solutions work. He lowered his glasses and looked at me like I was an alien.

He then quipped "You understand you are asking me to assign my staff to you, while they are working other projects where they can be compensated?"

For those who judge the ministry staff on per diems, it's an official mandate from governments to cater for consulting time. Imagine each day, over ten partners come in with different projects, all demanding the same staff time. They have to work overtime with no compensation while meeting their own work targets. To offset this, an official per diem structure was made for a structured engagement.

I replied to the Director, "I want to believe the government can also initiate projects because they believe in saving the lives of mothers and children as well as the community at large and not because someone is funding an idea. I have read all your books and I know you have a great passion for saving lives overall and have done groundbreaking work and research."

That stunned him. He moved to the shelf and picked one of the books he had authored (he had written and co-written several books, policies, and frameworks on groundbreaking medical works) and asked me what it was about. I summarised it with precision and quoted some of his field experience. That was the icebreaker. He asked me how I did it (that he knew more than half of his staff hadn't bothered to engage with his writings) and I told him, I had walked through almost all divisions of MoH while trying to find out a formula for engaging them to advise on projects. They all stated they would support me on condition they got a memo from the director. In the process, I discovered the MoH was a treasure trove of publications, all of which were free. I collected as many as I could and would read while having my morning tea or sitting in offices for hours waiting to be granted access to different heads of departments or divisions.

He called his team. And made an introduction. Then he quipped, "The problem with all these dot coms is they think an SMS can save lives. Every single day, I get bombarded with hundreds of solutions purporting to save lives. It's unclear if their ideas or solutions are saving lives during pregnancy, labour, at birth or post-natal. I know their heart is in the right place but they need guidance to appreciate what it takes to save a life. Work with her."

I got busy. Fitting in the medical staff cycle as I appreciated they had no time for workshops. To understand the challenges and opportunities for innovations, I had to walk the journey with the nurses, midwives, clinicians, laboratory experts etc, and fit in their schedule. It was while trying to understand what it would take to link a partograph to mobile phone alerts in a complex referral system that aimed to link doctors and midwives that I witnessed the outcomes of giving life firsthand.

A partograph helps to monitor maternal and fetal well-being during the active phase of labour and supports decision-making when abnormalities are detected. The challenge was most of the maternal, newborn, and child health units (MNCH) were understaffed. In one severe case, two staff attended to six births in a night. Fortunately, all the births were positive but the staff were wiped out; I had to shelve all my planned engagements with them on innovations for that day.

Realistically, an app could help generate demand but the supply side of health needed to be ready. If developing a content solution to help mothers manage their nutrition, mothers would follow it. If it has reminders for ante-natal and post-natal care, they would turn up to a facility but if the facility had no staff, medicine, running water, or electricity then it undermines their need to seek care.

As I moved around different facilities including in rural areas, I saw a delivery bed that resembled a slaughterhouse that hadn't been cleaned for a whole year. I encountered a rural clinic where community members held torches at night so the midwife could deliver a young lady as the facility had no electricity or running water. Community members fetched water in buckets and boiled with salt to sanitize it. The lack of stocked and screened blood banks added to the complexity of saving a life in the case urgent blood was needed.

Over and above health facilities infrastructure challenges, I learned the leading cause of maternal deaths were postpartum hemorrhage, sepsis/infections including from HIV-positive mothers, hypertension, obstructed labour, anemia due to poor diet and also not adhering to supplements given during pregnancy, abortion/miscarriages, and gestational diabetes (if not managed well, it can kill both mother and child) amongst other causes (malaria, cholera, diabetes, cancer etc). Venereal diseases and other infections contracted before pregnancy or during pregnancy such as syphilis, gonorrhea, HPV, hepatitis etc could lead to stillbirths or the infection of an infant. In some cases, extreme gender violence also impacted negatively on the mother and her unborn baby.

The protocols for managing a mother who was HIV-positive included testing for the disease as soon as a pregnancy was detected. Husbands/spouses would be required to turn up for the test but almost 90% of the time, they didn't turn up, or if they turned up, they would decline a test, stating, "If the mother is negative, then I am also negative." The challenge with data capture to enable a mother to be put on ARV during the entire pregnancy as part of preventing mother-to-child transmission was a breach of data privacy. The viral load of a mother would need to be tracked and if it was ≥1000 copies/mL within four weeks of the due date, the most likely outcome would be a cesarean delivery.

Depending on the status of the mother, hospitals would use the HIV drug zidovudine through an intravenous (IV) catheter to reduce the risk of HIV transmission to the child. Mothers were required to stick to the schedule and doses of ARV treatments but some for one reason or another failed to comply leading to drug resistance. Some mothers were open to automated reminders on ARV while others didn't want their status to be known or feared someone would see the alert and know their status.

Some public health facilities barely had a budget for protective gear for the medical staff including access to prophylaxis in case of accidental exposure while delivering a HIV positive mother. Families would be advised to purchase the protective gear.

The ethical debate on where a patient's data sits became center stage. Do you host a system in a cloud and have the data hosted locally and securely? Should a patient be allowed to decide who accesses their data? A lot of the data was ultra-sensitive. There was a school of thought who argued that a patient case file should be maintained including all history to allow effective care and treatment/referral while others argued that the data could be used to destroy the reputation of a patient. Ministry of Health legal team had to be consulted to determine the minimum viable data that could be collected to provide good care without violating the rights of a patient.

The government required tracking of maternal deaths, but staff would simply refuse to do it because they feared victimisation when a lot of the causes of the deaths were beyond their control such as lack of well-equipped facilities and understaffing. Trying to negotiate that this data could help pick trends and inform interventions didn't yield any results. There was a need to trace where the tech started and stopped and face the reality of linking demand and supply and concerns of family and data privacy amidst other healthcare intricacies.

But the bottom line, all agreed that the loss of a mother or child or both was a tragic outcome and would work together for more positive outcomes.

Key Takeaways

1. The survival of a mother and child is a community responsibility. The ecosystem around the mother needs to be her support structure for a positive outcome. Maternal and child health is not solely a woman's problem or responsibility.
2. Dads/spouses need to accompany their wives throughout the journey and invest in good health care options. The onus for sexual reproductive health and subsequent family planning shouldn't be dumped on the women. Collective efforts ensure positive outcomes for the baby and the mother.
3. An app can generate demand, it can help alert a risky situation, but governments need to invest in all aspects of health facilities.
4. Blood banks can only keep blood for 120 days due to the nature of the component tissues' life span. Some advanced countries have sophisticated tech for preserving blood platelets etc for longer periods but most facilities in Africa don't have it. There is a constant need to keep the supply fresh.
5. Medical staff don't have facilities like toilets and bathrooms to use after a long day's shift and they compete with patients. Some crossed to restaurants to access their facilities. In most cases, no special meals are prepared for staff. They would be lucky if they got some of the food prepared for patients. Yet this is the same team that worked so hard to save the lives of mothers and their newborn babies.
6. According to WHO, 2020 data, the maternal mortality ratio in the African Region was estimated at 531 deaths per 100 000 live births. Countries with extremely high maternal mortality rates were South Sudan with 1223 deaths, followed by Chad with 1063 deaths and Nigeria with 1047 deaths per 100 000 live births.
7. Countries with the lowest maternal mortality rate were Sweden, Netherlands and Norway with as low a rate as between 1-5 deaths per 100,000 live births/a rate that has been maintained for over 20 plus years. Their success is attributed to investing in the health system, physicians, and a network of highly qualified midwives.
8. A negative outcome impacts dads, mothers, and extended families including the children whose mothers died at birth. The long-term psychological impact is understated. The entire family should work to support a mother in her journey to bring life. Governments should be held accountable for quality maternity and newborn care facilities.

In Conclusion

No mother should lose a life while giving a life, each child has a right to live to their full potential, and every dad/community has a right to rejoice at the positive outcome of a new life (mother and child).