Posted by Duncan Maru, MD, PHD
All too often in our work, we are confronted by deaths of young people that are devastating by their impact on families and communities and by the fact of their being so preventable. The death of this young pregnant woman and her child, described below in the mortality report led by Nyaya physician Dr. Man Bahadur KC, is one such instance. Twenty eight weeks pregnant, started getting sick six days before coming to Nyaya’s Hospital, treated by a traditional healer, and transported by family members to Bayalpata Hospital, her unborn baby likely dead on arrival, she herself died shortly after evaluation by our clinical team. Her death is one that simply is not allowed to happen in many parts of the world, even among extremely poor communities, that have basic access to obstetrics care. My wife is an obstetrical resident physician at Boston Medical Center, serving some of the most impoverished and vulnerable pregnant woman in the United States. Despite the complex lives of her patients, which include substance abuse, severe poverty, and entrenched sexual abuse and physical violence towards women, structures are in place that prevent the types of deaths described below from occurring. These deaths happen all too frequently in Achham, and they are wholly preventable. This terrible death is an awful reminder of the long road ahead we have to achieve one of Nyaya’s core missions: closing the approximately 200-fold higher risk of maternal mortality among women in Achham when compared to those in the United States.
What is to be done by groups like ours working in rural South Asia to combat these daily tragedies? In a recent PLoS Medicine article on “Alternative Strategies to Reduce Maternal Mortality in India “, a group of Harvard researchers undertook a mathematical model to answer this question. They took demographic and clinical data from India and applied it to a simulation to predict the number of maternal deaths that would occur if different strategies were deployed. They identified services that could reduce maternal mortality by 80% at a cost of $500 per life saved:
- increased family planning services
- expanded access to safe abortion services
- additional training of skilled birth attendants
- improved care before and after birth
- reduction in home births
- roll-out of emergency obstetric care, including blood transfusions and cesarean sections
Importantly, they found that without emergency obstetric care, reduction in mortality would not go higher than 30%. This indeed is the major bottleneck that Nyaya Health has hit in preventing deaths among our pregnant patients. We have started family planning and safe abortion services. We are working on getting women in for antenatal and postnatal care. By providing high-quality services at the hospital, we are working to encourage deliveries outside of the home. But getting cesarean section capacity has proven difficult, with the number one challenge of finding a trained obstetric surgeon willing to live in Achham. This lack of human resources is not a Nepal-specific problem; it is a global problem. To circumvent this, some countries, such as Mozambique, have developed programs aimed at training midwives to perform cesarean sections.
In the mortality review below, our team, led by Dr. KC, discusses the structural problems that led to this woman’s death. The problems in many ways are clear: structural violence of the caste system (she was a Dalit, the “lowest” caste) ; lack of roads (she lived 8 hours away); lack of access to modern medical care (she received care from traditional healers during the critical six days from the onset of her symptoms prior to her death). Finally, a critical contributory factor to this woman’s death at the hospital-level is that Nyaya remains without an intensive care unit or surgical obstetric services. The solutions are also clear, as the PLoS paper demonstrates. But the implementation of these solutions are complex, and our own inadequacies in the short-term to prevent these awful deaths are maddening.
Note: this report is a part of our “Comprehensive Morbidity and Mortality Review” initiative aimed at cataloguing and reflecting on the underlying causal pathways in cases of excess morbidity or mortality. This work is supported in part by a grant from the Lovejoy Foundation at Children’s Hospital Boston, Massachussetts, USA.