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Background: In Malawi maternal mortality continues to be a major public health challenge. Going beyond the numbers to form a more complete view of why women die is critical to improving access to and quality of emergency obstetric care. The objective of the current study was to identify the socio-cultural and facility-based factors that contributed to maternal deaths in the district of Lilongwe, Malawi. Methods: Retrospectively, 32 maternal death cases that occurred between January 1, 2011 and June 30, 2011 were reviewed independently by two gynecologists/obstetricians. Interviews were conducted with healthcare staff, family members, neighbors, and traditional birth attendants. Guided by the grounded theory approach, interview transcripts were analyzed manually and continuously. Emerging, recurring themes were identified and excerpts from the transcripts were categorized according to the Three Delays Model (3Ds). Results: Sixteen deaths were due to direct obstetric complications, sepsis and hemorrhage being most common. Sixteen deaths were due to indirect causes with the main cause being anemia, followed by HIV and heart disease. Lack of recognizing signs, symptoms, and severity of the situation; using traditional Birth Attendant services; low female literacy level; delayed access to transport; hardship of long distance and physical terrain; delayed prompt quality emergency obstetric care; and delayed care while at the hospital due to patient refusal or concealment were observed. According to the 3Ds, the most common delay observed was in receiving treatment upon reaching the facility due to referral delays, missed diagnoses, lack of blood, lack of drugs, or inadequate care, and severe mismanagement. © 2012 Combs Thorsen et al.
This study was carried out in compliance with the Helsinki Declaration. Ethical approval was granted by The College of Medicine Research Ethics Committee in Malawi (Proposal No. 10/08/703) and The Regional Committee for Medical and Health Research Ethics in South-Eastern Norway (2008/16105). In addition, permission to conduct the study was obtained from the District Health Officer, District Nursing Officer, director of the hospital; senior head nurses at both sites, and the village headman or chief in the respective communities were informed. A descriptive retrospective case study design was used and qualitative methods selected to conduct an in-depth investigation and analysis of the circumstances and events surrounding individual cases of maternal deaths. Malawi is one of the poorest countries in the world, both in terms of income and human development. The total expenditure on health was 4.8% of its Gross National Product in 2009 (ranking 142 out 190 countries) [10]. In 2010 it ranked 153 out of 169 countries with comparable data accessible to the UN in the Human Development Index [11]. It has a predominantly agricultural economy, based mainly on tobacco grown in the central region, sugar and tea in the southern region and timber in the northern region. With most of the population highly dependent on rain-fed subsistence farming, there is widespread food insecurity, as well as rampant poverty. For the 2000–2009 period, 74% of Malawians lived below the international poverty line of US$1.25 per day [12]. In Malawi maternal healthcare services are provided informally through traditional birth attendants (approximately 5000 practicing, of which 2000 have been trained by the government [13]). Formally, they are provided by midwives, nurse-midwives, clinical officers, general medical doctors, and gynaecologists/obstetricians. The provision of healthcare occurs at three different levels (primary, secondary, and tertiary) that are linked by a referral system. All maternity-related services are offered free of charge in government facilities and in some non-governmental facilities. At the primary level, maternal services are managed by nurse midwives who manage only normal deliveries, except for a few facilities that conduct vacuum extraction. Most Christian Health Association of Malawi (CHAM) hospitals and district hospitals in the public sector provide emergency obstetric care (EmOC) includes the administration of parenteral antibiotics, oxytocic drugs and anticonvulsants, as well as the manual removal of the placenta, the removal of retained products, assisted vaginal delivery, surgery (cesarean sections) and blood transfusion. Facilities that provide the first six are called Basic EmOC facilities, while others performing all eight signal functions are called Comprehensive EmOC facilities. According to the World Health Statistics 2011, there were 3896 nursing and midwifery personnel, and 257 physicians in Malawi for the period of 2000–2009 [14]. Respectively, this represented a density estimate of 3 and less than 0.5 per 10 000 population. Malawi has one doctor per 62 000 population and vacancies among obstetrician–gynecologists, pediatricians, surgeons and other medical specialists range between 71–100% [15]. Vacancies among nurses stand at 65%. Another challenge is the uneven distribution of the workforce. Of the 190 Physicians who participated in the 2007 health personnel census, 62%work in urban areas, 23% work in rural areas and 15% work in semi-urban. Of the 2932 nurses/midwives who participated, 38% work in the urban areas, 33% work in rural areas while 29% work in semi-urban areas. Conversely, nurse technicians and medical assistants work predominantly in the rural areas (40% and 68%, respectively). The study was primarily conducted at two urban comprehensive emergency obstetric care (CEmOC) units of a secondary and tertiary hospital approximately five kilometers apart in Lilongwe, Malawi, with clinicians shared between the two sites. Together they have a catchment area of approximately 4 million inhabitants. The secondary hospital services non-paying patients, while the tertiary hospital has a mix of paying and non-paying clients, as well as referred clients from within and outside the district. Together, the maternal death numbers are estimated to be one per week, with a range of between two and six per month. Other characteristics of the facilities are provided in Table 1. For the time period January 1, 2011 and June 30, 2011, women who died while pregnant or within six weeks of being pregnant, had received care or delivered at either hospital and resided in Lilongwe District prior to their death were included in the study. Specifically, the medical charts of deceased women, healthcare workers who provided care to the deceased women, family members along with guardians of the deceased and traditional birth attendants were purposively sampled. The authors decided that a sample size of 20 to 25 cases was acceptable in terms of generating a comprehensive assessment of the contributing factors leading to the maternal deaths, as this range aligned with those observed in the literature. Guest, Bunce and Johnson identified seven sources that provided guidelines on actual sample sizes which ranged from five to 60 [16]. In Mason’s research in which he reviewed the abstracts of doctoral theses relating to interview-based qualitative studies in Great Britain and Ireland, he observed that sample sizes ranged from one to 95 [17]. The actual sample sizes were 32 maternal death charts, 34 healthcare workers, and 27 family/community members. The sample sizes allowed us to reach the saturation point. The principle of ‘saturation’ implies that the data collection is completed when no new insights or concepts emerge and/or when available participants have been exhausted [18]. For this study the saturation point occurred when respondents began repeating similar issues they or their deceased loved ones faced during the course of the complication to death. Data collection involved three activities: chart extractions, facility-based interviews, and community-based interviews using three different data collection tools adapted from the WHO guidelines: “Beyond the numbers: reviewing maternal deaths and complications to make pregnancy safer” [8]. More specifically, the following tools were used: The data that were extracted from the medical charts (e.g. the age of woman at death, the gestation weeks, the number of years of education, and amount of time elapsed between pregnancy and death) were analyzed using Predictive Analytics Software Statistics 18.0 (PASW, formerly known as SPSS Statistics). The analysis was descriptive in nature. The transcripts from both the Facility Staff Interview Questionnaire and the Verbal Autopsy and Contributing Factors Questionnaire were analyzed using a directed approach to content analysis [19]. This approach was used because the Three Delays Model and existing maternal death research helped determine the initial coding scheme and relationships between the codes which Mayring has referred to this as deductive category application [20]. The transcripts were read carefully to form a general impression of what healthcare staff and family members said about the respective maternal death cases. The transcripts were then re-read to understand the context in which the maternal deaths occurred. Based on the definitions of the three phases of delay, all text that appeared to describe any of the delays were highlighted. Through the deductive category application all highlighted text was compared and sorted according to the predetermined categories of delays in deciding to seek care, reaching a facility and receiving care once a facility was reached. For each category, the data was reexamined to determine whether subcategories were needed. Text that could not be coded into one of these categories was coded with another label, which led to the addition of one new category. For each maternal death case, the data from the respective medical chart and interview transcripts were triangulated to gain a more accurate account of what transpired. Based on the International Classification of Diseases tenth version (ICD-10), clinical judgment and experience, two gynecologists/obstetricians independently reviewed the triangulated data for each maternal death and determined the causes of deaths. They either confirmed the documented causes of deaths or provided alternative causes. Where appropriate, they also provided insights on what could have been done differently to potentially prevent the deaths. One of the gynecologist/obstetricians has worked in the study sites since 2004. He was instrumental in establishing the Norwegian-Physician Exchange Program (Norwegian doctors provided technical assistance, worked in the maternity ward for a 6-month rotation). The other gynecologist/obstetrician has over 20 years of experience working in various countries in Africa, including Malawi.
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