COTW: Maternal Mortality

by Rachel

A woman died on my service Thursday.  Now, people die every day around the world, and of course people die every day in Burundi.  Even more so in the hospital.  But this was a woman I had fought for.  Was fighting for.  A defeat in many senses of the word, which is always hard.  

She had come to a health center, in labor with her 5th baby.  You would think that birth becomes routine, especially after four normal deliveries.  But this time, something went wrong.  Instead of the baby’s head coming out first, an arm slipped into the birth canal and the baby turned sideways.  She was transferred to Kibuye Hope and my colleague did a C-section to deliver the baby.  It was a little bloodier than some, but went well overall...until they finished the surgery and pulled off the drapes to discover that she was lying on the table in an ever expanding pool of blood.  I was called in to assess the situation.   By then there was blood everywhere.  We did a hysterectomy and I removed her uterus as quickly as I could, although I left her cervix behind (a common variant of the hysterectomy often used after a C-section because it’s quicker and easier).  The bleeding seemed to stop, and we wheeled her back to maternity.  I have no idea how much blood she had lost by this point, but I do know she was in desperate need of a transfusion.  Our blood bank was empty (again).  Our neighboring hospital in Gitega, 30 min away, sent one unit by ambulance.  I returned to her bedside an hour after the hysterectomy, and the blood had just arrived.  She was still unconscious and now having gasping respirations.  And unfortunately, she was now in another giant puddle of blood.  We rushed her back to the operating room and I discovered that, perhaps all along, the cause of her profuse hemorrhage had been a large tear on the inside of her cervix, perhaps due to the baby’s arm, maybe due to the delivery.  I repaired it.  The unit of blood was emptied into her veins.  There was no more blood to give.  She died less than 30 minutes later.

Burundi has one of the highest maternal mortality rates in the world.  Almost one in every 100 deliveries ends in the death of the mother.  So, if a woman has on average 5 children, she stands a 5% lifetime chance of dying during or immediately after one of her pregnancies.  Incredible.  Incredibly sad and tragic.  Most of those deaths are due to hemorrhage, infection, or obstructed labor without access to a C-section or other proper care.  I don’t even know how many of these deliveries ends in the death of the baby, but it’s also quite high.  This particular case hits harder because she came to us.  She was in the best place possible.  She had a US-trained OB-GYN caring for her.  And we failed her.  Maybe that’s not true, but it feels like it to me.  

I grieve for her baby, born alive but who stands a high chance of dying in the next few months because there is no mother to give milk, to provide care.  I grieve for the husband and four other children who have lost a mother and wife.  I grieve for a country that doesn’t have the basic infrastructure to provide life saving blood (On a side note, reading US literature on postpartum hemorrhage/PPH, the protocol states that as soon as you diagnose PPH, order SIX UNITS OF BLOOD from the blood bank.  I doubt there are six units available within a 2 hour drive of here).  And although it seems selfish, I grieve for myself.  The “What if” game is a hard one to play, especially as a physician.  If only I had managed her differently, perhaps one unit of blood would have been enough.  I know that the outcome probably would have been the same, and on most levels I feel like I did everything I could.  But it’s hard on these days, to be a stranger in a strange land, to feel like I’ve given up quite a bit of normal life to be here for just such a time as this, and to feel a woman slip through my fingers.

Many times people read our blogs and ask, what can I do about this problem?  It’s a tough question to answer.  I do have some thoughts.

1.  Raise awareness.  Every day, the number of women who die in childbirth is equivalent to a 747 jet crashing into the ocean.  It’s awful.  There are organizations that seek to fight this.  You can start here.  I can’t speak to the specific ethical issues of every organization involved, but it’s a good place to start.

2.  Give blood.  Women’s lives are saved every day in the US because of the selfless gift of blood donation.  If not for that, the mortality rate after US deliveries would probably be quite a bit harder.

3.  Be grateful.  Sometimes I hear Americans in support of home birth use the argument “A hundred years ago, everyone gave birth at home.”  Yeah, and a lot more women died.  I’m not saying that home birth is the wrong choice for some people.  But be grateful for the medical resources that save lives every day.  Be grateful for your access to them in case of an emergency, no matter what.

4.  Pray. Pray for justice and healing and a world where things like this no longer happen.  Where every woman has access to a safe and healthy delivery, where women don’t have to be afraid of losing their life every time they get pregnant.