HEALTH WORKER TALES: When a mother refused emergency C-section at 2a.m at a remote facility

HEALTH WORKER TALES: When a mother refused emergency C-section at 2a.m at a remote facility

KGHRespectful maternity care (RMC), which is a universal human right that is due to every childbearing woman in every health system, is trending lately. And evidence shows that women’s experience with maternity caregivers can empower and comfort them, or inflict lasting damage. At a recent weeklong training of Health Centre IV personnel from select facilities in Eastern Uganda that are to be covered under our Maternal and Newborn Scale-up (MANeSCALE) Project, RMC was a captivating topic punctuated with several anecdotes. It from the many stories that Kakaire Ayub Kirunda recounts one from a medical officer (name withheld) at a Health Centre IV in Mayuge District- Eastern Uganda to kick start our “Health Worker Tales” series in which we shall be sharing short stories from health workers as they struggle to improve maternal and newborn health in a challenging health system.

“It is 2a.m and here comes a mother. A gravida 3 [three previous pregnancies] with two previous scars due to CPD [Cephalopelvic disproportion- baby’s head or body too large to fit in the pelvis] and she clearly needs an emergency C-section. The midwife calls me, I tell her to prepare the mother and would join them shortly for the operation. I review the mother and we head for theatre. But as we are on the table, the mother asks me whether I was going to administer general or regional anaesthesia. I am like, at this time we do not have access to an Anaesthetist. I would like to help you and save a life. I can give you GA [General Anaesthesia] and monitor you successfully. I request we do GA and conduct the operation. The mother says no.  ‘For all the operations I have gone through I have been getting regional anaesthesia. Why do you want to give me general anaesthesia?’

“She refused. But this was a mother with a big baby. She had a very crooked pelvis and by the time I reviewed her she was 6 centimetres and was having persistent and strong contractions. But she has rights which I had to accept. I however explained to her the possible complications but she refused. I was left with no choice but to suggest to her referral which she accepted. We communicated to Buluba Hospital but they couldn’t answer the phone. So we advised them to go to Iganga Hospital. But even getting transport at that time of the night was hard. So they left only for us to discover later that they went to a TBA (Traditional Birth Attendant). We also learned that while there, the mother got obstructed. They eventually went to Iganga General Hospital. I followed up with a call to Iganga and I was told they managed to save the mother at around 11a.m. but the outcome was a fresh stillbirth. The baby was 4.8 kilogrammes.”

Such is the dilemma that health workers find themselves into in an era of respectful maternity care. In this case, while the rights of the mother were respected, this action resulted into a preventable death of a baby she had kept alive for nine months. Could the mother’s failure to appreciate the doctor’s advice have come as a result of bad antenatal?

4 Comments

  • Could she have feared the lack of anaesthetist and preferred regional anaesthesia?
    It is hard to understand why she did not even go for an elective c/s and thought of going to a TBA. Could this make us look at the quality of antenatal care(health education), could it have been somehow individualized for her state?
    Did she miss out on the most crucial health talk for her situation?

    Kalende Reply
  • Partly but far from entirely certainly. Chances are that ANC (if she attended) could have emphasized the need for an elective Caesarian section. A lot must have explained including the responsibilities of the mother. However I don’t see this midwife, or whoever provided the ANC explaining the details of anaesthesia that would be given to this mother. I even don’t see her being explained that “the anaesthetist” might not be present when (or is it if?) she comes in for the C/S. Often, the assumption is that this woman who has had 2 previous caesarian operations knows it all. Was it even explored what type of anaesthesia she had received and therefore other alternatives that exist? Most likely not. I am not tempted at all to apportion blame on the ANC care because I know frequently there is an attempt by Health workers to do there best. However there are many other occasions where “our” best is not good enough. Hence the need for Continuous Quality Improvement (CQI). So now we identify a problem or several of them here. Is it the comprehensiveness of the ANC care? Is it about the staffing? Is task shifting for anaesthesia an option at all for such a facility? Probably something else! Solutions then can be attempted and the cycle(s) of analysis repeated over and over again until near perfection.

    Hector Tibeihaho Reply
    • Good systems issues that you raise Hector. This case study provides an opportunity for learning and reflection on both the supply and demand side of health care services. Thanks for reading and taking time to share your views. We appreciate. And we are open to expert opinion and blogs whenever you get sometime to write.

      admin Reply

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