Sunday, May 9, 2010

Medico Legal

I went on vacation for a couple of weeks recently. When I returned, everyone on labor ward welcomed me back warmly.

“We missed you!” they said. “We had to refer SO many mothers!”

Sigh. Apparently, if I’m not around, no one does the cesareans, and they all get referred to St. Anthony, the private hospital.

As I was chatting with some of the midwives, I learned that while I was away, a woman died after delivery. I feel guilty. I know in my head that it is OK to go on vacation, but it seems terrible that a woman should die just because she had the bad luck to deliver when I was on holiday. It’s just as bad as a woman dying because she comes in after 5pm. It makes me wonder what is going to happen when I leave in 2 months. I guess this was the preview.

She died of hemorrhage. She was delivering her seventh child, and she came in and delivered very rapidly, and started hemorrhaging right away. When a woman gets postpartum hemorrhage, it can be a slow, insidious hemorrhage that just won’t stop, or it can be a rapid, frightening, unbelievable amount of blood. The uterus has a massive blood flow in pregnancy and if that’s not reduced after delivery, she can die within a matter of minutes.

This woman died in two hours. In that time, the midwives were unable to give oxytocin because the hospital had run out. They were unable to give ergometrine (methergine) because it had run out. They were unable to give Hemabate because it is too expensive and isn’t available in Uganda. They were unable to give misoprostol because the hospital has never had any – it was banned in Uganda until this past June because of fears that it would be used for illegal abortions.

The midwives here are quite good at infant and maternal rescusitation – they can do bimanual massage, hang fluids and give the right medicines if they are available. But they can’t do anything surgical. They called for help, but no one came.

The lack of oxytocin is a reflection of a larger problem. The hospital has not received its shipment of many supplies and medications because the payment to the National Medical Store, which is transferred directly from the Ministry of Finance, has not been made yet. The hospital usually operates at a bare minimum, and now they have reached far beyond the ridiculous. The hospital is out of metronidazole (a common antibiotic known as Flagyl, one of the few antibiotics they ever have), HIV testing kids, and syringes, to start. They have been out of skin cleanser for weeks, so instead of scrubbing the patient’s skin before surgery, we pour saline over it, which is pointless, but makes us feel better. Gloves are scarce. Patients (or their family members) are being sent to town to buy gloves and syringes so that medication can be given.

The midwife who tells me about the maternal mortality told me another story, equally disturbing in a different way.

A few days ago, three TDH midwives were arrested.


Yes: Arrested.

This is what happened, as it was recounted to me. A woman was admitted to Labor Ward with severe malaria. She was started on IV Quinine, and during her admission, she went into labor. Her labor course was normal, but when she reached around 6cm dilation, she started pushing. This was her first baby, and she was thrashing wildly and not listening to the midwives as they exhorted her to stop pushing.

Pushing against a cervix that is not fully dilated is not a good idea. It can cause the cervix to swell – which can impede dilation - and pushing against a cervix can hurt the baby if it is prolonged and forceful enough. This is one of the myriad benefits of pain management in labor – it reduces the urge to push before the body is ready – but that is not an option in Tororo.

Finally, the patient reached full dilation and managed to deliver. Upon delivery, the baby seemed very tired, as the midwives say. The stress of labor had caused the oxygen in the baby’s blood to decrease, and the acidity to increase. This is what is known as birth asphyxia, a frighteningly common outcome in poor resource settings.

Some infants who look hypoxic upon delivery are merely transiently depressed – they get resuscitation and perk up immediately. Resuscitation can include stimulation, oxygen, assisted ventilation, chest compressions, and administration of dextrose. In my experience, the midwives here are pretty good at resuscitation – they aren’t as structured or formal about it as we are in the US, but they do everything they can do. However, often oxygen is not available, and that is a key component.

Some infants are worse off– the ones who have been compromised for longer – and do not perk up with resuscitation. In order to predict the long-term outcome of the infant, we use the Apgar score at 1 minute after delivery, and 5 minutes after delivery. The first number tells you the almost immediate status of the infant, and the second number tells you how the infant did with resuscitation. If that second number is still low, it is not good.

In this case, the infant had Apgars of 3 and 6 (out of 10). So it did improve, although not completely at 5 minutes. Eventually, though, the infant looked well and was put under heating lamps, and later given to the mother.

The midwives decided to give the infant Gentamicin (not sure why, it is common here), and when it was time for the dose, they had to send the husband to town for syringes. When he returned, they went to give the IV Gentamicin, and found that the baby looked unwell and re-initiated resuscitation. The resuscitation failed and the baby died.

A few days later, the Tororo police came to arrest the midwives who were involved with the care of the mother and the infant. From what I hear, there was some confusion, and a lot of stalling for time. The police seemed perturbed to be arresting the midwives without being allowed to make a formal complaint.

The three midwives were taken down to the police station, and other midwives gave statements from the labor ward. The three arrested were charged. The midwife who delivered the baby was charged with assault (apparently the woman was charging that the midwife had beaten her and caused the baby to die). The midwife who performed the resuscitation was charged with child neglect. And a third midwife was charged, but I am not sure with what.

I heard the story from various people, and everyone had different pieces of information. It was confusing for that reason, and also because in the end, it made no sense. Why would a midwife beat a laboring woman so badly that it would cause the death of a full-term fetus? The woman would have to have some serious injuries for that to happen - did she? And there are usually many people in the labor ward – it could never happen without being witnessed (abetted, really) by other midwives, patients and family members. The idea of it is just preposterous.

In addition, the way the matter was handled was suspicious. If the patient and her family were unhappy with the care they received, why didn't they go to the hospital administration immediately, instead of waiting to be discharged and then going to the police? And why was the matter reported to the Kampala police when the incident occurred in Tororo? And on top of that, why were the Kampala police commanding the Tororo police to arrest without investigating? It was not consistent with proper procedure, and the Tororo police were not happy about it. There were suspicions that some family member of the patient had connections in Kampala with either the police or an important politician. It's all conjecture, but it is highly possible, given how strange everything was.

It sounds as if that baby had plenty of reason to do poorly. The woman went into labor while being treated for severe malaria – malaria in pregnancy is associated with both stillbirth and neonatal demise. An earlier episode of malaria might have weakened the fetus even before this episode. Pushing against a closed cervix for a long period of time can be dangerous for the fetus – the uterine forces combined with valsalva can be a lot of pressure on the fetus’ head, and if it is prolonged, can cause damage. It would make sense that the feuts had a localized swelling on its head where it was being pressed against the cervix. Lastly, this was the patient’s first delivery. Most likely her labor course and length of pushing was longer than multiparous women – more time for birth asphyxia to develop, especially in a previously compromised fetus.

I heard from one of the midwives that the family had taken the body to Mbale for an autopsy, and that the autopsy result was apparently absurd. The report, I was told, declared that the infant died of “poor resuscitation” and “neglect.” In case you are wondering, neither of these is a cause of death. A cause of death is something like “respiratory failure” or “trauma” or “hemorrhage.” Furthermore, the person who wrote the report could never have known if the resuscitation was “poor” and the child was “neglected” unless they had been there at the delivery. If this is really the autopsy report, there is suspicion that someone was paid off to make this report, or else the person who did it was non-medical.

The midwives, needless to say, were up in arms. If those three can be arrested (and I know all three – they are good, skilled, competent midwives), then any of them can be arrested. And for that matter, so can I. These midwives work for pennies, they always show up for work (unlike almost everyone else) and they work HARD. I am volunteering my time – I don’t need to be there at all, and yet I go there to work 7 days a week. None of us needs the threat of prosecution added to our concerns.

After being charged, the arrested midwives needed someone to stand for them to be released on bond. Each was able to have either her husband or a fellow midwife stand for her, and they were released and told to return on Tuesday.

The midwives clearly needed to vent, and they talked over each other to tell me the different parts of this crazy story. Finally I asked them what I could do to help them. (In some situations here, having a mzungu helps but in some, it hurts. If money is involved, you will always be charged more if you have a mzungu with you.) They asked me to go and speak with the hospital administration and ask for their support of the midwives.

It was Saturday when I first heard the story, and I stewed all the way until Monday, anxious to speak with the Senior Hospital Administrator. When I did meet with him, I first asked him what the situation was. He recounted the story for me from his perspective, which was similar to the midwives’ perspective. He was not here when the police came – which would explain why he was not able to go to the police station that day.

I then told him that the midwives were very upset and I was alarmed. He was quite sympathetic and concerned, and together we decided to call a meeting with the midwives to reassure them of the hospital administration’s support of them. We also agreed to have the Nurses and Midwives Council Representative contact the Council in case they needed further assistance, like legal representation.

By coincidence, we had scheduled the meeting for the exact same time that the midwives were scheduled to report to the police station, so we decided to delay the meeting. Several midwives were planning to accompany the accused midwives to show support. I asked them to decide whether it would be better or worse to have me there. They decided it would be very helpful, and so I dropped everything to go down there. In addition, the Operating Theatre staff also wanted to attend to show support.

We gathered in groups to walk to the police station, about a 15 minute walk. I walked with several of my favorite midwives. It was a great walk. We laughed, held hands, made mzungu-Ugandan jokes (“Mzungus talk funny!”) One midwife started singing a civil rights song, and then I started in with “We Shall Overcome.” One midwife started explaining to the others that mzungus bring so many things to Africa to help Africans, and that mzungus have taken on the burden of Africa. I tried to explain gently that it was a bit more complicated, that mzungu countries are not exactly innocent (in the past or now), but they didn’t really care. They were mostly trying to say they were grateful for the mzungus who come to help, so I didn’t push the discussion.

When we got to the police station, we waited. The three arrested midwives were sitting inside an office, and as a large group, we waited outside. Then I decided to take some photos since I had so many midwives in one place, and they were all dressed up beautifully. I tried to have a random man take a photo of us with me in it but he couldn’t handle framing the photo, holding the camera still, and pressing the button (which I’ll admit I have always taken for granted), so the picture is askew and cuts off several heads. Still, I got some good ones.

We waited and waited. We chatted about various things. More people arrived, including both anesthetists, some nurses from other wards, a clinical officer, and eventually the Senior Hospital Administrator. We were probably at least 20 people at that point. We kept expecting the police to finish their paperwork and then head down to court for the hearing, and all of us planned to follow.

Finally, after about 45 minutes, the police told the midwives that they were still not sure about this case, and they wanted to investigate further. They told the midwives to go back to work, and the police would call the midwives if/when they were needed.

I didn’t understand at first, but it turns out this is a very good outcome. It means the Tororo police (we think) are not happy about being forced to arrest without being allow to investigate, and are suspicious that the charges were made in Kampala and not Tororo. Hopefully, this will lead to a quick resolution for these falsely accused midwives.

Nonetheless, the episode has put everyone on edge. It is scary to think that this kind of thing could happen again (although admittedly it is rare). Working here with the bare minimum – and now even less than the bare minimum, without even syringes to give medication – bad outcomes are going to happen. We can do our best, but these are not the best circumstances. Babies are going to die, and sometimes mothers. The only way to prevent this is to improve the system, and that takes political will.


One of the midwives who walked with me to the police station asked me about the malpractice situation in the US. She was thinking about applying for a nursing job there, but was scared off by all the rumors she had heard about lawsuits. Thankfully, physicians, nurses and midwives in the US are not at much risk of being arrested, but the threat of litigation is indescribably stressful and has damaged the practice of medicine.

In Uganda, bad outcomes are assumed to be part of life – despite what we do, sometimes they happen. In the US, we have reduced the morbidity and mortality associated with birth to such a degree that we have forgotten what nature really does. We can control it – or so we think. When bad outcomes do happen, we are shocked because they are so rare, and we assume it must be someone’s fault. If the outcome is bad, there must be someone to sue. Babies don’t die being born, women don’t die in childbirth.

We tell ourselves that our litigation system provides the motivation for doctors and nurses to do the right thing. Working here, I doubt that theory more and more. These midwives are not in fear of litigation and make very little money, and yet they work extremely hard under frustratingly limited circumstances. Their work ethic rivals that of even the most hardworking health professionals in the US, and I think job satisfaction and camaraderie have a lot to do with that.

Because they are not blamed when bad outcomes happen, they can take risks that we can’t. They deliver breeches vaginally. They can wait for a protracted labor to take its course. When a cord prolapse happens (the cord comes out before the baby), they don’t run to a crash c-section; they know the baby is going to die. It means the c-section rate is lower, but it also means that infants die when they don’t have to. Is this good, or bad?

In the United States, we are schizophrenic. We blame obstetricans for over-medicalizing birth, and yet when bad outcomes happen, we want to sue them for not preventing it. We beat our chests over the high c-section rates, and yet birth asphyxia, stillbirth, neonatal death and maternal death are unacceptable outcomes. We allow the natural birth movement to make a lot of noise, but we can’t accept what nature actually does during birth. We want to have our own personal physicians care for us for nine months and then come in at the drop of a hat to catch our babies, but we don’t want to pay doctors enough to make that possible.

Where would I rather give birth? Hands down, I would rather be in the United States. I want safety, resources and an epidural.

Where would I rather work? I am not sure. I am tired of working long hours, skipping meals and giving up my personal life to care for patients in need, only to hear stories at parties and on TV and in the newspaper about how terrible, greedy, arrogant and selfish doctors are. I don’t mind working hard, but the constant haranguing is demoralizing.

I want to work in a place where I have the appropriate resources to help my patients, but I also want to work in a place where people appreciate what I am doing. But it seems that the more resources we have, the less we appreciate it.

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