Maternal Mortality

Eve is doing a retrospective and prospective analysis of maternal mortality at Mbarara Hospital. She showed me some of the case notes.

I noticed that a lot of them, at least half, receive the postmortem diagnosis of severe malaria, although almost no workup has been completed. Blood smears are usually requested, but no results are ever recorded; I saw only 2 that had blood smear results. Eve records this as “diagnosis based on clinical criteria.” I wonder how many of them really die of malaria. The lack of availability of laboratory diagnostics (the patients have to pay for them and often can’t afford them) and the poor record keeping make this sort of research difficult.

With Eve’s permission, I’m posting some of them, with some details removed.
This is one:

Age: 20
Date of death: Hospital Day #12
EGA: 32 weeks
Death during delivery: No
Clinical diagnosis:

• Arrives complaining of two days of fevers, chills/rigors, severe lower abdominal pain, no history of neck stiffness of convulsions or bleeding
• Was given injections at clinic with minimal improvement
• Weak, difficulty speaking, severe pallor of mucous membranes, feverish, some dehydration
• Reports cough with white sputum
• Fetal heartbeat present
• Impression: malaria in pregnancy

Interventions:

• Blood smear requested, no results on file
• IV quinine
• Paracetamol
• IV fluids
• Antibiotics
• Delivers in hospital (stillbirth) with minimal blood loss
• Given oxytocics
• Blood transfusion requested but no blood available for four days. Patient died four minutes after blood arrived.
  

Cause of death: Severe anemia from clinical diagnosis of severe malaria.