Friday, January 4, 2013

The Numbers

Here are the figures for the Global Calender year just finished, plus the numbers for the year before, 2011, and then for comparison, 2009 which was the last full calender year before the volunteers recruited by the Barbara May Foundation began arriving half way through 2010. What the figures clearly show is that Andrew Brownings vision, that having volunteer obstetricians here would save lives, was clearly correct. In 2009 over 60 women, at least one every week was dying, but since then even though significantly more women are coming to give birth in Motta, in the last two years only 9 have died. This is because we are now able to do caesareans for women in obstructed labour and for women with a ruptured uterus:

Outcomes  :  Mothers and Babies
                                                                    Shegaw Motta District Hospital
2009(Before BMF)
1st Full year
2nd Full year
Mothers admitted
Normal Birth
734   (70%)
Forceps & Vacuum
173     (26%)
189    (18%)
191   (18.5%)
Destructive Delivery
Caesarean Section
88     (8.7%)
111   (10.7%)
79       (9.3%)
Maternal Death
60   at least  (1:12, 8.1%)
5        (1:200)
4        (1:250)
Perinatal Deaths
Unreliably recorded
106    (10.5%)
79      (7.5%)

I looked back at the other figures Ive kept from 2011. In regard to uterine rupture, I was expecting to find fewer in 2012 - my hypothesis was that women with obstructed labour would come earlier as knowledge spread about the expanded service at Motta, and they would get here before the uterus had ruptured, but to my surprise the number had doubled between 2011 and 2012 to a total of 22, the opposite of what I was expecting. What does this mean I have been asking myself?  I think it might mean that because word is getting out that survival is possible,  more and more women in that dire situation are being brought in rather than allowed to remain at home and die. In 2009 and earlier the enormous effort required to bring such a sick woman from inaccessible rural areas achieved nothing – she died. Now there is hope!
Women Walking (Note men carrying nothing!)
My hypothesis that women might come earlier for help does have some support however, in the fact that Destructive deliveries have almost halved, from 11 to 6.  I realise one shouldn’t read too much into such small numbers, so it will be interesting to see what happens to that statistic this year. Destructive deliveries occur when the woman arrives with a dead baby that is stuck with a fully open birth canal, but the uterus hasn’t yet ruptured so the baby is “removed” without having to do a caesarean. If the woman had come earlier, when the  baby was still alive we would have done a caesarean. So if women were deciding to come earlier when runing into trouble we might expect to see fewer of these ghastly "destructive" deliveries, more caesareans and fewer perinatal deaths! 

And indeed that is what the stats show! Yes, we are doing more caessareans, there are fewer dead babies being delivered and fewer dead mothers - well OK, one! - as a result I hope of women realising there is help here if they get her soon enough!  Again, the numbers are not huge and all these stats may just reflect random fluctuations in outcomes, but a reduction in perinatal deaths from 10.5% to 7.5% if real, is a significant result. In the west perinatal deaths are often under 1%, and maternal deaths are something like 1:12,000 births, so theres still a long way to go.  
The other number I thought was interesting was that the big jump in the total number of  admissions between 2009 and 2011 didn’t happen again between 2011 and 2012. We know that something like 90% of women give birth at home in rural Ethiopia so there is still a massive catchment out there and we only assist a small fraction of it.  So why aren’t more continuing to pour in? I suspect the total number of women may not increase much more from here because most of the women who can come already do – the rest just live too far away to be able to get here. The reality of course is that the majority of women giving birth anywhere do it successfully and both mother and baby survive. However if the nearest road is a four hour trek along a narrow country track, and its nightime and there are no buses, and there is no ambulance to call and no phones even if there was one, by the time its realised that the birth is all going horribly wrong, its too late.
And by the way, I think Andrews next plan is get an ambulance.

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