When numbers mislead: Making sense of increasing maternal and newborn deaths within Uganda’s complex referral system
“Figures often beguile me,” wrote the American author Mark Twain in 1906, “particularly when I have the arranging of them myself…There are three kinds of falsehood: fibs, lies, and statistics”. Apparently the latter [statistics] is the most aggravated. That numbers devoid of context are meaningless should be BIG news in the world of science which is largely [quantitative] data-driven; however most would naturally scoff at this.
A lot has been said about numbers – particularly how they don’t lie. However the more progressive and balanced argument is that while numbers don’t lie, they don’t tell the whole story either. In health systems research – specifically in maternal and newborn health (MNH) – where I currently work, this point (again!) came to life this week. We’ve been hosting Ms. Ingrid Lidman, a representative of Social Initiative which funds one of our projects called MANeSCALE (Maternal and Newborn Scale Up) in Uganda’s Eastern region. The project aims to improve quality of care (QoC) for mothers and babies around the time of birth in hospitals; this against the backdrop of WHO and national QoC targets to reduce health facility deaths of mothers and babies by 50%. Initially MANeSCALE worked in the six hospitals within the region but has recently expanded its interventions to also support lower lever health facilities (LLFs) – specifically HCIVs – with large volumes of MNH work. The goal of this is to decongest hospitals while also improving access to quality care. We also seek to strengthen the referral system across this network of hospitals and Health Centre IVs (Sub-district level facilities), also supported by the ELMA Foundation. Interventions include provision of key MNH commodities, conducting training and clinical mentorship for healthcare providers, data strengthening and leadership engagement.
Back to numbers and lies, or is it half-truths? While significant MNH improvements have been achieved since project inception, MANeSCALE’s quarterly report for May-July 2017 also showed increasing numbers of newborn deaths from 69 to 99 deaths, a 43% increase in the region. Jinja Regional Referral Hospital reported the highest increase in newborn deaths from 8-33 which is a 76% rise. So the question Ms. Lidman and all of us have been asking is “why?” – why an increase and why Jinja which is the regional leader. In trying to dig deeper we spoke to a senior midwife at Jinja Hospital who confirmed data we continue to gather from multiple sources that the main barriers to newborn survival are mainly late referrals from LLFs which increase both mortality and morbidity risk. “Referral challenges, including the lack of decent and timely transport, mean that mothers arrive very late at facilities. Then we have to deal with obstructed labour, severe birth asphyxia and injuries as well as infections. Also some of the referral cases have first been referred somewhere like Buluba before Buluba also refers them here [Jinja]. By the time they show up it’s too late and we can’t do much… some we manage to keep alive for some time but it’s not possible all the time to save every baby.” So while LLFs show reduction in newborn mortality – with some registering zero mortality, Jinja Hospital bears the brunt of “owning” a large fraction of them while most of the time it is providing referral support and leadership as expected of a regional referral hospital. The downside to this is damning hospital statistics and possibly misguided performance appraisals by those who read the numbers.
But there is hope – building capacity in newborn care is at the core of MANeSCALE’s current work in LLF. We’re setting up functional neonatal units complete with OPD follow up clinics (such as the one in the image on the right at Jinja Hospital), building health worker capacity, reviving maternal/perinatal death audits and getting all facilities to “talk” and learn from one another in order to prevent avoidable maternal and newborn deaths. That done, we anticipate that the MMR and NMR numbers will not only be evenly spread across facilities but will, in fact, be significantly reduced. More leadership from hospitals within the network. More capacity and power to LLFs. No more numbers without context as they can be extremely misleading or altogether wrong.
*Written by Dr Gloria Seruwagi, a post-doctoral research fellow at the Makerere University Centre of Excellence for Maternal Newborn and Child Health.