Maternal Mortality: The Three Delay Model and maternal “near-miss” concepts

Maternal Health

On August 22, 2012, the New Vision Newspaper, also the government’s mouthpiece, published an optimistic overview of the 5^th Uganda Demographic and Health survey, 2012 released by the Uganda National Bureau of Statistics (UBOS). This report cast a surprising appraisal of the health sector that disputed the increasing apathy among Ugandans towards healthcare services.
Of particular interests were maternal health and mortality rate. According to UBOS, there are more pregnant women visiting antenatal clinics and are receiving preventive care such as immunization against tetanus and regular monitors of vital signs such as blood pressure; more women delivered in public health facilities in 2011 than the previous years and; a decline in the number of women who delivered from home or in transit, were recorded. Most notable is the reported decline is maternal deaths - from 550/100,000 in 2001 to 438/100,000 in 2011. By any standards, this report exceeded expectations and should be received with much delight.
The United Nations’ 2012 “The Millennium Development Goals Report”, indicates that the antenatal care for pregnant women has improved significantly across the world and that for Africa; Southern Africa continues to lead in achieving concrete gains in this aspect. Despite general improvement in antenatal care across the world, Sub Sahara Africa’s achievement in all the Millennium Development Goals was the slowest.  For instance, in 2010, an estimated 287,000 maternal deaths occurred worldwide, which is 47% decline from 1990. Of these maternal deaths, Sub-Sahara Africa (SSA) accounted for 56% and Southern Asia 29%. This is 85% of global burden of maternal death (245,000 deaths) between SSA and S. Asia.
Given the colorful status of the 5^th Uganda Demographic and Health Survey report, many Ugandans who have endured challenges to access basic health care services will have to ask many questions. Such baseline demographic reports are often not very representative. Attaining credible statistics that is representative of maternal status in Uganda is nearly impossible because of adverse culture of record keeping; most deaths in Uganda are not reported, and even those that are reported, may not be accompanied by exact cause of death. Obtaining credible statistics requires stringent and massive resource allocation, for which, with the pervasive nature of corruption and incompetence in supervision, collection, monitoring and verification of data, one doubts the credibility of such demographic or health data.
The International Classification of Diseases, in its 9^th and 10^th Revisions (ICD-9, ICD-10) defines maternal death as “the death of a woman while pregnant or while within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to, or aggravated by the pregnancy or its management but not from accidental or incidental causes”. ICD discerns maternal death from direct obstetric death which results purely from obstetric complication of the pregnant state (pregnancy, labour and puerperium), from interventions, omission or incorrect treatment, or from the chain of events resulting from the aforementioned.
It is of utmost imperative for frontline health care providers to understand the above classification of the causes of maternal deaths if UBOS and other researchers are to ever get credible data. There are conceptual models that have helped us to explicate the underlying preventable and avoidable causes of maternal deaths. Most practitioners are aware that pregnant women die from complications of heamorrhage, sepsis, abortion complications, hypertensive disorders, obstructive labour, ruptured uterus, ectopic pregnancies and complications resulting from HIV/AIDS, Malaria and waterborne diseases, among many.
However, for public health policy and ethics of practice, the three delays and “near miss” model developed by Thaddeus and Maine (1990) should help to reinforce the knowledge of challenges that pregnant mothers endure trying to access antenatal care. According to Thaddeus and Main, many pregnant women do reach health facilities in such a poor condition that they cannot be saved, and the time taken to receive adequate care is key factor in their deaths. The three delays; delay in deciding to seek care by the woman and/or her family feeds into the delay in reaching an adequate health care facility and, the delay in receiving care at that facility.
Each of these delays is facilitated by certain key factors motivated by poverty or attendant socio-economic inequalities. Thaddeus and Maine named women who survive death from pregnancy complications, either by chance or by receiving timely care as maternal “near-miss” and argued that these woman share similar experiences with those who died due to pregnancy complications.
The three delays model has profound implication for practice and research. First, that the establishment of public health facilities and infrastructure that is supportive and accessible to the child bearing woman is a collective virtue. Further, it calls on the moral imperatives and ethical responses from health care workers to prioritize the care accorded to women, whether pregnant or not. This also has major implication for health policies, funding and leadership to ensure a reduction in the interval between onset of a complication and its efficient management in all health facilities.
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Structural deficiencies explains the health sector’s failures

HealthCare

The article, “Irresponsible living partly to blame for straining Uganda’s health sector” by Dan Kimosho in Daily Monitor edition of August 23^rd, 2012 needs an urgent rebuttal. Mr. Kimosho argues fervently from a rather skewed perspective that Ugandans who get ill or those who find themselves in need of medical care, are the ones who strain the health care because of their irresponsible living. In his views, if Ugandans were to live a more carefully crafted lifestyle and were to take responsibility for their health situations, then the health care system would not be strained! He cites examples of rampant accidents and injuries secondary to road accidents and others.

I spent a number of years at Mulago, in the rehabilitation department as trainee. I must state categorically clear that from my own perspective as practitioner, the real causes of the rampant ill-health, accidents and reasons for seeking health care services in Uganda and elsewhere are associated with structural deficiencies at all levels of government.

I do not have to be technical in my analysis here. Take for example road accidents. I do not have current statistics on how many people die on Uganda’s roads or how many accidents occur in a year. But we all know that road accidents which are completely avoidable remains the top killer and cause of injuries as well as disabilities in Uganda. When we look at the statistics of accidents involving boda boda, either motor-bike or regular bicycles, the figures will stun you. Why?

There are many other situations that are inevitable and yet the ordinary Ugandan has no power to overcome, just by merely living responsibility. Let us look at hygiene among slum dwellers. The drainage systems and the facilities in slums around the urban centers all over Uganda are not adequate to contain the ever rising population. In fact, the UN has estimated an exponential rural to urban influx in most of Africa in the face of population explosion by 2030. It is even evident that most of the migrants end up in low accommodation areas that are quickly transformed into squalid slums. Are our urban planners taking heed of such significant policy matter?

Notwithstanding space limitation, both cases of increasing road accidents, disabilities, and the surge in urban population have profound public policy implications. These are areas that we have neglected, thus, the failures of structures and mechanisms to regulate opportunities for safe and responsible living.

We must agree that victim blaming is a very unfortunate and superficial way of diagnosing a social problem. Symptoms are not causes but manifestation, we must not forget this. The transportation infrastructure in Uganda is very poor, as such; people have tried to navigate the system despite its discrepancies to eke a living. Where public transits, buses, omnibuses or taxis cannot reach because of poor roads, Ugandans will devise means to reach, inevitably.

When we see people acquire avoidable water borne diseases, or get disabled, we must think first that they did not choose such a destiny. As public servants, we should be critical and sensitive to causal factors to enable us remove such barriers. I contend that the health care system has not been expanded to meet the ever expanding and chaotic situation of human living in Uganda today. This is primarily due to two factors; lack of political will to strengthen the health care system and lack of healthy public policies on a wide variety of human discourses, including transportation, housing and accommodation, sanitation, equity and equality as well as culture and cultural practices.

Further, the health care system in Uganda is too biomedical and we must diversify to embrace alternative practices. I have advocated for investment in more upstream health care approach where people are given skills to make healthy choices and decisions before they become ill. The Ugandan system still narrowly defines health as presence or absence of infirmity, this is very limiting.

The government should adopt health promotion strategies, principles and practices in all its policies. Every decision we make profoundly impacts on the health of individual or communities amidst us. When families or communities lose their bread winners in road accidents, such event redefines life experiences in such households and impacts negatively on the health status of the community. The existence of socially structured inequalities and inequities in society implies that the health of the population is thwarted. The real problem is with us, the technocrats; we blame the victims of our shortsightedness for their predicaments.

I contend that there has not been a systemic and critical study of the failures of our healthcare system in supporting its population. But any healthcare system that over relies on biomedical paradigms are failing world over, so paradigmatic shift is inevitable.
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Is Obama robbing surburbs to pay for cities?

This is a rebuttal to Conservative writer whose article appeared in the Forbes Magazine insinuating that Obama is a modern day Robinhood. The link to original article is included at the end of this rebuttal

Dear Prof. Stanley Kurtz,
I am hoping that you are fine. I am writing to you in response to your article in Forbes Magazine and perhaps a book with the title: “How Obama is robbing suburbs to pay for the cities” (link included below). I read this article with much pain in my heart. I am not intending to drum sentimentalism here but to share with you my honest feelings about the so-called Conservative values espoused in this article, considering how skillfully you presented your case/ observation.

I am not an American but I may qualify as a global citizen. I find glaring and widespread social inequalities and inequities in most of the communities where I have visited and worked in public life. I suppose that most of these inequalities are socially and historically entrenched and in your country, it is even etched in America’s over 400 years of brutal history. I have seen the poor people and I have failed to understand how the right wing American Conservatives, somehow, constantly blame these wretched of the earth, for their predicament.

I think as a Health Promoter and someone who is neither democrat, conservative nor liberal, I find that the main cause of insecurity in the world is desperation as a consequence of deprivation (unequal distribution and access to resources). And we know that our society is one that is not a perfect one, it is that made of balanced acts in life (the poor, very poor, the rich, wealthy, middle class, thieves, scoundrels, jesters etc). This variation is in itself the reality of the inequalities that humanity endures. There is no utopia or exception anywhere on earth. So, the conservatives should face this reality with much courage!

Now, from your article, you make it obvious that there are no poor in suburban America. I would like to contest this misleading attitude. Most Conservatives make it sounds as though by the order of providence, only the middle class and the 1% occupy American suburbs, such that any attempts to alleviate the social conditions of the urbanites (read the poor) constitute a major violation of the conservative conscience.

I read that you are interested in ethics and position of religion in modern society. I wonder how you would interpret Kantian ethics, due diligence or utilitarian ethics for me as someone who is passionate about uplifting and alleviating humans from the humiliating poverty and destitution in which they are ensnared - a fate that they may not have willingly chosen. Are there Conservative thinkers who really believe in the principles of Health Promotion in America?

I think and I believe that you will be enticed to rethink, that whatever the actions taken by those community mobilizers in Chicago, including Barack Obama, were noble causes – a compassionate cause to reduce, arrest, revert or deter the institutional perpetuation of inequalities - for those people who are already powerless (lacked the means to access education, legal representation, property rights, justice etc). I contend that the reason why most of you so-called middle class people are ensconced in surburbia is the paranoia of the destitute. It is also that strange greed (sense of utter entitlement), where those who have are afraid to share openly and honestly with those who don’t. But how do people like you accrue so much wealth, control so much resources and wield so much power without exploitation of workers and those consumers in the abyss of society? In other words, most of the entrepreneurs reach out to the impoverished to procure their labour and/or compromise their virtues.

It is also strange but true that the typical right wing Conservative is obsessed with Christian and family values and yet, ironically, they do not walk the Christian talk. So, when I hear John McCain, Paul Ryan, Sarah Palin, Limbaugh and all the right wing Conservatives disparage and make mockery of the poor, I feel the strange wiggling of the Christ in utter protest.

I think that the Obama administration has performed remarkably well in light of the government they inherited from the Republicans. In as far as reducing the loopholes that permit exploitation, especially on Wall Street and in small alleys, they have done remarkably well. They have reversed to some significant extent the threat of foreclosures. But you cannot blame the Obama administration for outsourcing of American jobs overseas that created the foray of joblessness either. Neither can you blame him for being a modern day Robinhood simply for helping in alleviating urban destitution.

Otherwise, I enjoyed reading your well articulated article. I only felt that you were not being intellectually honest and socially compassionate for blaming Obama for his role as community mobilizer. I hope this piece will be received in good faith. I must state that I have been humbled in composing this email to you and it represents my very honest opinion

http://www.forbes.com/sites/realspin/2012/08/13/how-obama-is-robbing-the-suburbs-to-pay-for-the-cities/

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Where does Museveni’s vision originate?

THE OLD VISION

Every time that the issue of succession and power transfer comes up for public discussion, somehow we are quickly and sternly reminded that Uganda, a population of over 34millions does not have visionaries. This position is delusional and one tinged with nothing but utter fear. This fear is not about how Uganda will do post Museveni, it is a situation where a man becomes fearful of his pictures in the mirror. The old Museveni with vision now fears the new Museveni without vision.

Museveni has been in power since 1986. The children who were born in 1986 are the ones running amok in the streets of Kampala jobless and realizing sadly that their promised future has been squandered. Museveni must be wondering and asking himself, what kind of a father breeds his children and conditions them to rely on his vision until they are past the age of twenty six? Most properly groomed African families expect their children to have their own lives and dreams at the tender age of 18 for liberals and 15 for conservative individuals.

Now given that Museveni has publicly and privately chided his comrades in the struggle, that none of those people have a vision and are not trusted with the country, the question we should be asking is, where does this peculiar Museveni vision come from? Is it divine?

Here is a theory that may perhaps explicate this vision mystery. The 1980 Museveni who had morphed from Fronasa claimed that he had a better vision for Uganda. Later he politically seduced a bunch of indolent youths into the bush to form his original 27 guerillas. One would assume that in the process, they shared a common vision and aspiration. The NRM ideology and the many point programs that came to pass were supposedly not created by Museveni alone. There were ambitious young men in his tow, who shared vision, shaped and reshaped the path to what they considered good governance and a better Uganda. They all aspired for a Uganda that would treat everyone equally and on merit.

These men for sure espoused similar vision with that of Museveni. If they didn’t, then how come Museveni never shared this strange vision with the rest of his men? I have argued again that it is very difficult to trust Museveni because he has no commitment to anything, not an agreement, not to conscience either. It is further humiliating and annihilating for the men who have supported this regime at every possible opportunity, only to be humiliated in public that after all, they are as mediocre as every other peasant – with no vision.

One really wonders where and when Museveni acquired this gold standard vision upon which every other contender’s ability to govern Uganda is being measured. Clearly the Museveni of 1986 did not envision Uganda with potholes, corruption, nepotism, tribalism, barbarianism, dilapidated healthcare system and all that we live by now. This is perhaps the reason that Museveni of today, lives in the shell of the Museveni of 1986.

But for Museveni, he will soon realize political isolation. This is when he will revert to the heightened use of brutality for companionship. Ugandans are making strong statements through the numerous bi-elections against his disastrous vision. If he is not listening, then he will realize late that his vision has faded. Uganda is no longer a bastion of hope, but of gloom. It is a place where the fundamental principle of reciprocity has long been traded for the very ills of vanity.

But my confidence is that Ugandans are very visionary. This is how they were able to hold their turf against colonialism, Idi Amin and all the other brutalities that they have endured. The same way other leaders have left the scene will most likely be replicated, because even Idi Amin didn’t believe that there were visionary Ugandans. That is primarily the reason he prematurely declared himself President for life.

Finally, let us be truthful and honest to you, Mr. Visionary President. Uganda is ready for change if you are not. Do not hold us hostage to your vulnerability. Ugandans have resorted to civil mannerism to seek for this change. Do not under-estimate the simplicity embedded within this civility; it is a deviation from your mindset of genocidal strategies.

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