Ndembou C. Jean-Louis
|Maternity ward of Bafut District Hospital, 2017|
“Doctor, we have a thirty-eight-year-old lady, recently injured, having difficulties bearing down. And her baby’s heart rate is not the best,” a harried sounding nurse gushed over the phone. I groaned inwardly and reassured her I would arrive at the maternity ward in about ten minutes. I instructed her to continue monitoring mother and baby while waiting for me. In the semi-darkness of my bedroom, illuminated by the light of my smart phone’s screen, I ruefully slipped my feet into my flip-flops. The nippy draft caressing my skin nearly convinced me to return beneath my cuddly blanket. But duty prevailed and I found myself dressed and in the gelid street at 2 a.m. on my way to the hospital.
I am always amazed at how this same situation never grows old. Consider, for example, the significance of a first child born to a couple that had been childless for a long time, living in a society where childlessness is seen as a curse or a sign of great wrongdoing. For another couple with seven girls, it may be the first time she bears a son. Another situation would be the only child of a widow giving birth to her own first and maybe fatherless child in a community where posterity is as vital as your name. Maybe I should be breaking out in cold sweats when I consider that my decisions and actions could affect the balance of their lives.
Yes I know, you, Reader, may ask, “Those doctors, do they have feelings?” I have also been in situations where a perfectly calm doctor communicates woeful news sublimely and without feeling. For those first seconds, you are speechless. It is not the grief taking your breath away, and you even want to congratulate the doctor for his courage, but that would be indecorous. Then you think, who gave him the audacity to bear bad news, even if it is his duty? Who says the bad news was not his fault? You vent your rage to the heavens, then attack him, if only in your fertile imagination.
Maternal mortality is an important topic in Cameroon and a common reason for doctors to have to deliver bad news. Sub-Saharan Africa alone contributed 56% of all maternal deaths in 2010.1 Compared to a Maternal Mortality Ratio (MMR) of 210 globally, sub-Saharan Africa has the highest ratio in the world with 500 maternal deaths per 100,000 live births.2 Though there was a 47% global decline in maternal deaths from 1990 to 2010, Cameroon has steadily increased its numbers from 1989-2011.3 The greatest factor for maternal mortality in the world, and even more significant in Cameroon, is hemorrhage.4
Our thirty-eight-year-old patient was actually forty-one, one of those tactical errors that can happen on birth certificates. She became pregnant, using her words, after obtaining the assistance of several donors and finally finding one efficient enough to get the job done. It was her very first baby, and she also was an only child. Her successful “donor” had promised marriage only if she succeeded in this crucial endeavor of childbirth. She had fallen off the bike that was bringing her to the hospital when it missed a maneuver on the sorry road from her village. She was bleeding and terribly exhausted, and her baby’s head was already in the birth canal. I ordered certain drugs to be administered and took up monitoring myself. My heart rate nearly overtook the rising one of the baby as I surreptitiously dabbed at my forehead when I was sure none of the nurses were looking. I nearly pushed along with the mother as everyone shouted, “Push!” and various other encouragements. As I opened my mouth to request that she be prepared for a Cesarean section, she was delivered of her baby.
There was silence in the room as everyone turned to look first at the unmoving baby, and then at me. I realized there was nobody I could transfer responsibility to, so I directed the people in the room, “Get the ball and mask, bulb syringe, and other requirements as per protocol. Form two teams of two, one starts neonatal cardiopulmonary resuscitation, the other continues care of the mother.” I hurried to join the team handling the baby, who squalled in an overwrought fashion nine minutes later.
“Doc, we may lose her,” the midwife said evenly, raising the test tube in which she had done a bedside clotting test.
“Great! There’s nothing like a freaky coagulation problem to up the ante,” I thought morosely as I watched the blood refuse to clot. “The last thing we need after this ordeal is a maternal death review.”
“Doc, we have been giving our best,” the midwife said. I commended their efforts and then requested urgent blood donation. The patient’s vital signs, which had been relatively stable till now, were plummeting. She was lethargic and her extremities were getting colder. The placenta was delivered along with a great deal of clotted blood. Following this, the bleeding got worse in spite of the medications we gave. I shuddered in my doctor’s shoes. My past experiences with coagulation problems had always been nightmarish, so I prayed this case would be different. After several pints of whole blood, ampules of uterotonic medication, a few inotropics for blood pressure, and a lot of bimanual compression, we all heaved a sigh of relief.
Maternal death reviews (MDRs) are one of the tools that have been introduced in health facilities to reduce maternal mortality. Maternal death is almost always avoidable, so there has been an international exchange of expertise. MDRs focus on prevention and quality improvement, avoid finger-pointing, and promote an academic and professional environment. It is a thorough investigation of the causes and circumstances surrounding a maternal death. The approach is holistic and takes an overview of both medical and community-based factors.5 Hopefully time and this ongoing work will help us change the dismal trend in Cameroon’s maternal mortality rate. I am glad to say that I contributed to the efforts that have helped bring a small improvement in neonatal mortality from 2004-2015.6
Several hours later I checked the patient’s vital signs in the postpartum ward. It was an exquisite near miss, and she did unfortunately have some later complications from the severe bleeding. But in that moment I was able to smile at her and her precious baby and say, “Congratulations Madame, we have all come a long way.”
- Mba Cypress, “INTRODUCTION TO MATERNAL AND NEONATAL MORTALITY EMERGENCY OBSTETRICS AND NEONATAL CARE CONCEPT, CHANGING OBSTETRIC PRACTICES” TRAINING OF HEALTHCARE PROVIDERS IN THE NORTH WEST REGION ON EMERGENCY OBSTETRIC AND NEONATAL CARE (EmONC), December 2016.
- De Brouwere V., Zinnen V., and Delvaux T., “HOW TO CONDUCT MATERNAL DEATH REVIEWS (MDR) Guidelines and Tools for Health Professionals” London, International Federation of Gynecologists And Obstetricians, FIGO LOGIC, August 2013.
- De Brouwere V., Delvaux T, and Leke RJ, “Achievements and Lessons Learnt from Facilitybased Maternal Death Reviews in Cameroon,” BJOG 121, no. (Suppl. 4): (2014): 71–74.
- Mba Cypress, “INTRODUCTION TO MATERNAL AND NEONATAL MORTALITY EMERGENCY OBSTETRICS AND NEONATAL CARE CONCEPT, CHANGING OBSTETRIC PRACTICES-TRAINING OF HEALTHCARE PROVIDERS IN THE NORTH WEST REGION ON EMERGENCY OBSTETRIC AND NEONATAL CARE (EmONC)” December 2015.
- Zinnen V. and Delvaux T., “HOW TO CONDUCT MATERNAL DEATH REVIEWS (MDR) Guidelines and Tools for Health Professionals.” London, International Federation of Gynecologists And Obstetricians, FIGO LOGIC.
- “Cameroun – Mortalité Néonatale Atlas Mondial de Données,” 2017, knoema.com.
NDEMBOU C. JEAN-LOUIS is a general practitioner at the Bafut District Hospital in Cameroon. He is most interested in quality of life for patients with chronic diseases and palliative care outcomes, in particular for HIV and cancer.