The curse of motherhood

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By Tsitsi Matope

MASERU — That many mothers have a chill down their spines each time they imagine what could happen if they decide to fall pregnant is a reality in Lesotho.

According to the 2009 Demographic Health Survey, out of 100 000 deliveries, 1 155 of the women die of pregnancy-related causes — the highest mortality rate in southern Africa.

‘Mamarake Ranku, 28, who is a mother-of-two, is one such woman who becomes terrified each time she imagines herself pregnant.

The death, on February 9, of Tlotliso Tsikoane, her neighbour, is the reason why she does not want to fall pregnant again.

“I will never forget how she suffered. She bled so much before passing away at the Queen ‘Mamohato Memorial Hospital. What really pains me is the chance she had to survive the child-birth, if the doctor at the hospital had admitted her right away when I took her there that Saturday morning (February 8).
It is this questionable decision that the doctor took that makes me fear for myself and also other women who might be planning to get pregnant,” Ranku said.

Tlotliso Tsikoane was a 32-year-old single mother who also had a physical disability.

She worked in the Thetsane textile factories in Maseru and the pregnancy that killed her was her second.
Her story is one of the many told in Maseru of how some women in labour are turned away at the country’s main referral hospital for different reasons, which include not having been referred to the facility.

Tsikoane, who was 40 weeks pregnant, died after undergoing an operation that saved the life of her 2.780-kilogramme second son.

Her first son died in 2012 when he was two years of age.

Ranku said although she took Tsikoane to hospital when she was visibly in bad shape, the doctor only prescribed some drugs and told her to go back home.

“This was the part I did not understand because she was bleeding a lot, and travelling by public transport was a problem. I had no doubt that she was in labour,” Ranku said.

According to Ranku, upon arrival back home, Tsikoane spent the whole day in bed and continued to bleed heavily.

“At around 5pm, I realised she had deteriorated a lot and decided to accompany her to a nearby filter clinic, Qoaling. When I arrived at the clinic, the nurses realised the baby was already coming and immediately referred her to Queen ‘Mamohato Memorial Hospital.

Despite her state, we had to use public transport since there was no ambulance.”

At around 7pm, Tlotliso was admitted in Ward J, according to the neighbour, before she was told to visit the following morning.

“When I visited the next day, I was told she was gone,” said a clearly distraught Ranku.
The late Tsikoane’s brother, Lekhafola, said the family suspects their daughter died as a result of negligence by the first doctor who told her to go back home.

“When she went to them for help the first time, they should have helped her. They told us that what primarily killed her was cardiac-pulmonary arrest but I think they will need to explain what caused it. My sister bled so much,” Lekhafola said.

The hospital’s report, he added, had also cited drug-reaction as the secondary cause of death.
“No amount of pain will bring her back, but what we want is justice in order to get closure,” he said.

The late Tsikoane was an orphan and her late mother’s sister, Maliengoane Malilimetsa, said she would look after the baby, named Bonolo.

“My daughter died because they did not care. Even when they could see her disability and the heavy bleeding, they still did not care to keep a close eye on her,” she said.

On her part, the Director for Operations at the Queen ‘Mamohato Memorial Hospital, Dr Karen Prins, said the hospital was very disturbed by the tragic outcome.

However, Dr Prins said telling patients to go home in the latent phase of labour is not an uncommon practice.

“The patient was not anaemic on admission and therefore, there is no substantiation of the allegations that she bled significantly,” Dr Prins said.

She further said preliminary investigations showed the late Tsikoane had a pre-existing medical condition that caused her untimely death.

“Although she already had this condition during her first caesarean operation, we suspect that it deteriorated significantly before the second pregnancy.”

It was not clear whether the late Tsikoane was told of this condition after the first operation.
Dr Prins also said two additional clinicians were called from home to assist while additional staff was also brought in, in an attempt to save Tsikoane’s life.

“The hospital has offered to have an autopsy done by an independent forensic pathologist to verify the cause of death,” she further said.

However, Tsikoane joined a list of mothers who have died at the hospital, sometimes leaving their babies behind.

‘Malerato Marasi from Teyateyaneng in the Berea District cannot forget how her daughter-in-law, the late Mpolokeng Tsoelipe Marasi, suffered just after undergoing a caesarean operation.

“She was worried about her children. The eldest, a boy, is just four years old,” Marasi said before breaking down in tears.

“What comforts me is the grandson she left me. Mpho (meaning Gift) is eight-months-old now. I wish she was here to see him grow. He is so handsome.”

The baby of the late Marasi, who was a radio producer and presenter, was only five days old when his mother died two days after the caesarean section.
“There is nothing we can do to bring her back; I wish there was something,” Marasi said.

According to her mother-in-law, the late Marasi went to the hospital after complaining of abdominal pain on May 28, going under the knife a day later to remove the baby.

“She had an abdominal pregnancy and hospital officials told us another procedure had to be done to remove the placenta. They also explained that it was not an easy procedure because the placenta would be attached to any part of the body.”

After the operation, she suffered heavy bleeding, ‘Malerato Marasi said.
“Some family members donated two pints of blood but it was already too late to save her. She died two days later,” Marasi said, adding what disturbed her was the doctors had failed to detect that her daughter-in-law had an abdominal pregnancy, on time.

“We did not know until when they had to operate,” she said.
Mission Impossible

Saving all pregnant mothers who suffer various complications is a mission impossible in Lesotho.
Dr Prins attributes the high death-rate to failure by every pregnant mother to access comprehensive services in some areas, inadequate healthcare skills, especially in the rural areas, poverty and some cultural practices.
“It is critical to identify and address all the barriers that limit access to quality maternal healthcare services to improve patient-outcomes.

“This would enable policy and lawmakers to make informed decisions on the impact of some of the laws that have a direct effect on maternal mortality.

“For example, legalising safe-abortion and quality post-abortion care should be considered to save the lives of women relying on unsafe backyard abortion services,” Dr Prins said.

She further said between January 2012 and December 2013, 47 mothers died at Queen ‘Mamohato Memorial Hospital, some of whom had been referred to the hospital from the country’s 10 districts, including filter clinics in Maseru. According to Dr Prins, out of the monthly average of 400 to 450 deliveries, there are 40—50 pregnancy-related referrals from the district hospitals.

“The majority of these cases, an average 19.4percent of all deliveries, end up as caesarean sections due to complications,” Dr Prins said.

She also said during the 20-month period (October 2011-June 2013), the highest killer of mothers was pregnancy-induced hypertension (preeclampsia and eclampsia), which contributed 33.9-percent of the mortality.

Maternal deaths due to post-abortal sepsis were 20.7-percent, 16.7-percent due to medical causes predominantly HIV and AIDS-related, 15-percent due to haemorrhage while other causes included puerperal sepsis, uterine rupture and abdominal pregnancies, she added.

“It is important to understand that the international norm is to calculate the maternal mortality ratio as the number of deaths per 100 000 live births. The national maternal mortality ratio is very high at 1 155 per 100 000. In 2013, the hospital was able to reduce maternal mortality by 57-percent compared to 2012,” Dr Prins said.

Despite the reduction, she said there was still need to continue improving the referral system and antenatal care to cure Lesotho of this scourge.

“In Lesotho, we have a basic patient pathway that starts from the village health-worker and moves up progressively to the community health-centre, the district hospital and to the national referral hospital.

However, several components of the proposed referral system are not working as expected. A lot of patients refer themselves to the hospital and these self-referrals negatively impact the provider-patient ratio,” Dr Prins said.

She added there was need to capacitate healthcare workers at district level so they could deal with basic surgical interventions to prevent unnecessary referrals.

“Although there is always need to recruit more specialists to work at various health centres, including at Queen ‘Mamohato Memorial Hospital, Lesotho, being a nurse-driven health system, has even greater need to capacitate midwives in basic emergency obstetric-care as well as training general practitioners basic surgical interventions to prevent referrals over long distances, a situation that can compromise the outcome of the mother and baby.”

To significantly reduce maternal mortality, Dr Prins said every woman should timeously access antenatal care during pregnancy, skilled care during childbirth, care and support in the weeks after delivery.
“It is particularly important that all births are attended by skilled health professionals as timely management and treatment can make a huge difference between life and death.”
Dr Prins also explained it was vital to prevent unwanted and early pregnancies.
“All women, including adolescents, need to access family planning services to prevent unplanned pregnancies that can lead to risky backyard abortions.”

The Director for Nursing Services in the Ministry of Health, ‘Makholu Lebaka, on her part, said over the years, there has been a number of strategies government has employed in an effort to reduce maternal mortality.

However, the continued upward-trend in maternal mortality showed there was need to review the current strategies and introduce new interventions in order to make a positive impact, she noted.

According to Lebaka, the decentralisation of the primary healthcare services reform programme currently underway introduced initiatives such as boosting the number of nurses from two to five, (three midwives and two nursing assistants) at all clinics in the districts.

Nurses and nursing assistants (230) working in the 46 hardest-to-reach health centres are also each expected, before April this year, to get incentives that include furnished accommodation, monthly hardship allowances of M600 and transport allowances of M250. The move is meant to make working in these remote areas, shunned by many care providers, attractive.

However, it is yet to be seen whether these initiatives have so far helped improve maternal health.
“A recent analysis conducted by the Ministry of Health will soon inform us whether or not we are on the right track,” Lebaka said.

She further explained how the Mother-Baby Pack initiative launched in 2011 was providing medicines, including Anti-Retroviral drugs and other medical necessities to pregnant mothers living in areas far from health centres.

The pregnant mothers are given the Mother-Baby package to take home for use the first time they visit the clinic.

Lebaka said apart from these national efforts, Lesotho could also learn from models that have worked in other African countries such as the Private Nurses and Midwives Association of Tanzania (PRINMAT).

n-profit-making organisation comprising of registered nurses and midwives.
“We can replicate such models; this is an initiative that has seen private nurses and midwives coming together and setting-up community health centres in the middle of nowhere like what characterises many of our rural areas.
These centres provide reproductive health-services at small community maternity homes throughout Tanzania. What is important about this initiative is that it is supported by the government to ensure sustainability,” Lebaka said.
Tanzania’s maternal mortality rate is at 460 per 100 000 live births. The PRINMAT programme was established in 1999 following the realisation that maternal deaths and complications were high in the majority regions of Tanzania.
PRINMAT uses a combination of approaches by clinics and grassroots integration networks to deliver care and educate communities. To increase the utilisation of its 52 maternity clinics and build demand for reproductive and safe motherhood services, PRINMAT has placed its emphasis on educating communities and involving men in issues of reproductive health, something that is missing in many rural villages of Lesotho.
Lebaka emphasised interventions should respond to the country’s challenging topography and also have the capacity to address and deal with the dynamics associated with the process of giving birth.
“Our interventions should be well-informed by the situation on the ground. We need to understand that when it is time for a baby to come, it cannot wait for skilled personnel or for the mother to reach a faraway health centre on a horse. That is why we need to strengthen community-focused and orientated healthcare developments. We must be realistic when it comes to deciding what works and what doesn’t work in Lesotho.”
She further said areas that currently need improvement include strengthening the community-based health workers’ performance and building the capacity of midwife-nurses.
“Although at the moment, there are midwifery and anaesthetist training collaborations with universities in the Free State, South Africa and Zimbabwe, we have also reviewed our midwifery curriculum. This is meant to strengthen our training systems to meet the kind of skills that the maternal healthcare sector is now demanding.”
Lebaka also revealed beginning this year, the training at all midwifery schools would become competence-based or practical-based and not theoretical as was the case for many years.

“We became aware that some of our midwives lacked the competence required to provide quality services. Apart from the curriculum review, beginning 14 January, we are also training 10 midwives in advanced midwifery to build capacity in managing complicated deliveries. We would like these nurses to be able to mentor others in clinics while at the same time, we sustain this critical training programme.”

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