I recently received a desperate call in the middle of the night from a doctor under my supervision at a hospital where I practice, informing me that a patient's uterus had ruptured (torn apart) during birth. The mother was referred to us because the hospital where she had delivered -- about 100 km away -- did not have blood for a transfusion. She had lost so much blood. The doctor calling me was desperate because the patient needed an emergency operation to remove her uterus. But our hospital also had no blood in stock. I instructed the doctor to continue looking for blood, and she phoned two hours later informing me that we now had two units of blood. What we needed was five or six units, but we had to take our chances and try to save the patient's life with what we had available. As we wheeled her into the operating theatre, her heart stopped. We vigorously resuscitated her and then proceeded to remove her uterus and infuse her with the units we had. She stayed in the intensive care unit for 3 days and got discharged home a week later.
She is one of the lucky ones who survived because we secured the blood we needed in the nick of time. So many hospital maternal deaths result from stock outs of essential supplies such as medicines, blood and laboratory testing kits.
Emergencies in pregnant women can deteriorate rapidly and require immediate intervention to avoid death. In 2018, the hospital where I worked had about 49 maternal deaths. Most of these deaths, according to the official maternal death review audits, could have been prevented had the patients received adequate care. Adequate care is often hampered by these stock outs and non-functional equipment. Zimbabwe has one of the highest rates of pregnancy-related deaths in the world, losing about 7 women for every 1,000 live babies born. Given that the country has about 450,000 live babies born a year, this translates to about 3,000 women dying a year due to pregnancy related complications.
In Zimbabwe, we are fortunate that our government has heavily invested and prioritized maternal and child health. According to the Zimbabwe Society of Obstetricians and Gynaecologists register, we have about 130 qualified obstetricians in Zimbabwe, the number having doubled in the past 10 years. About 90 percent of them are working in the public sector. In addition, in 2018, the government announced free maternity care for women. But, this investment will not result in better care for women and children if we don't ensure hospitals have the supplies they need.
While I recognise that financial constraints hinder the Ministry of Health and Child Care's desire to address this problem, the cost of inaction is higher. Doctors all over the country, including me, are frustrated by these shortages and preventable deaths. Our recurring doctors' strikes are arising out of this frustration. Right now, senior doctors in one of the five major referral hospitals in Zimbabwe have taken the stance that they will only do emergency surgery until the crippling supplies and equipment shortage in the hospital is rectified. In addition, doctors are leaving the public service due to frustration of working in such environments and the government is losing on its investment in training them.
It is extremely demoralizing to watch our patients die unnecessarily. You can hear the sadness and desperation in Dr Mashumba's (a paediatrician I work with) voice in her recent testimonial captured on video. "There is no urgency and there is no priority, and nobody is listening to us," she says. "I come to work to do my very best but my output are still births, my output are disabled babies…. what do we do?"
Through budget prioritisation, support from partners like UNFPA, the corporate world and the Global Fund, and a low-cost, government-run health insurance, we can ensure we have enough supplies and functional equipment to treat our patients. While the introduction of free maternity care was a noble move, it had to come with a funding mechanism to ensure sustainable, adequate, quality care. In terms of how we prioritize this support, we must start with the top-level hospitals as they receive the dire emergencies and often require the most expensive drugs to support their patients. Support can then filter down to provincial hospitals, and finally the lower level facilities.
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I also acknowledge that sometimes hospital deaths are caused by sub-standard care from attending doctors and these cases should be investigated separately. While it's important and cost effective from a public health point of view to target primary prevention, there will always be women who will develop complications requiring advanced care. The attending doctors must have all that is necessary to provide the best service.
In conclusion, the government through the Ministry of Health and Child Care must strengthen its effort to urgently ensure adequate and continued provision of medicines, functional equipment and other essential supplies to reduce preventable hospital maternal deaths. The human cost is unacceptable.
Mugove Gerald Madziyire is a consultant and lecturer at the Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences. He is an Aspen New Voices Fellow.
