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Public’s trust and maternal death
There are few more emotional topics for our population than maternal death. It must be an unimaginable horror for any family to spend months preparing to welcome new life into this world, and then to abruptly lose the mother and sometimes the baby as well.
The nature and extent of media coverage of any given case also can lead to significant trepidation among other expectant women regarding the safety of their own pregnancies.
In the year 2000 the largest gathering of world leaders in history recognised that maternal health required definitive action and determined that by the year 2015 countries would reduce maternal mortality by 75%.
Needless to say we in Trinidad and Tobago have failed miserably to achieve our target of a maximum of 14 deaths per 100,000 live births by 2015, although obtaining confirmed current statistics in this land is as difficult as getting nuclear launch codes from Air Force One. In 2010 our maternal death ratio was 46 deaths per 100,000 live births and in 2013 it was 63 per 100,000 live births so we are very far from “mission accomplished”.
The causes of maternal death include hemorrhage or bleeding, high blood pressure in pregnancy, embolism, unsafe abortions, and obstructed labour.
In many cases there is nothing inevitable about maternal death, and there are additional measures that we as a society can take to reduce its incidence. There is increased risk among adolescents, so improved adolescent health services, effective health and family life education, and improved reproductive health services for girls would make a significant difference.
The quality of prenatal care is also an important factor impacting maternal mortality. Generally each pregnant woman should have a minimum of 4 clinic visits and should benefit from proper screening (such as blood pressure monitoring) to identify risk factors, with provision of basic medication, counselling and advice on warning signs.
A related factor is the need for skilled and competent attendants to be present at all births with proper monitoring and response to emergencies as they arise. We must bear in mind that someone can be skilled but temporarily not competent as occurs for example if a nurse is saturated with fatigue or if a doctor is saturated with alcohol. We have some of the best doctors and nurses in this country, but just like with the police service a few rogues with atrocious attitudes can effectively devalue the entire sector.
Our Ministry of Health has become a legend in its own right at announcing committees and investigations, most of which never end or lead to meaningful implementation of recommendations. Indeed that Ministry has launched more probes than the Russian space programme but the problems persist and in some cases are worsening.
There is an almost complete absence of accountability in the health sector; often the medical fraternity protects itself, and the policy-makers view the negatives in the sector as a personal liability and predictably end up functioning in the role of public relations artiste and cover-up specialist.
We must not overlook the link between staff morale and improved outcomes.
Far too many of our health care providers are retained in demotivating and highly tenuous arrangements by the state, and workplace distress and victimisation, uncertainty over renewal of contracts, chronic staff shortages, experienced midwives feeling underutilised, substandard equipment and abysmal working conditions contribute to an environment in which service providers may not give of their best, with potentially serious consequences for service receivers.
At the end of the day we are left with a nation in which many deeply distrust the system of health care upon which they depend. This has created the perfect environment for suspicion, for the unreasonable assumption of neglect in all hospital deaths and negative outcomes, and for increasing tension between client and provider.
Some would take comfort in the suspension of 3 doctors related to a recent case of maternal death under the TRHA. On the face of it we should welcome the removal of those being investigated from the scene of the alleged wrongdoing so that they would be less likely to influence witnesses, manipulate files and other evidence, or repeat the transgressions pending the conclusion of such investigations.
Those among us who have been paying attention should be forgiven however for wondering firstly whether accountability really is the objective of such investigations, and secondly whether our Ministers and senior public servants would one day be treated in like manner when accused of letting down the public’s trust.
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