Background
According to estimates by the World Health Organization (WHO), there were 740 maternal deaths per 100,000 live births in the Democratic Republic of Congo (DRC) in 2005 [
1]. The DRC is thus one of 17 countries with a maternal mortality ratio higher than 700 in 2005. Hogan et al. reported lower, but not statistically different, estimates of maternal mortality, around 550 in 2005 and 534 [311-856] in 2008 [
2].
The most commonly suggested determinants of dismal figures like these are a low proportion of antenatal care and institutional births, both of which contribute to the facility-based approach to achieving Millennium Development Goal 5 (MDG5) [
3,
4]. In Kinshasa, however, the antenatal care coverage is high (96%), as is the proportion of institutional deliveries (97%) [
5]. The number of doctors is in line with international standards. Indeed, the ratio of physicians per head of population is 2.4 times higher than the WHO standard of 1:10,000 inhabitants; the ratio of nurses to population is 5.6 per 5,000 inhabitants compared to WHO standards of 1:5,000 [
6].
This apparent paradox of high coverage levels of institutional births with high maternal mortality level is challenging. Such a high level of maternal mortality may be explained by poor-quality care and by delays in uptake of care. Earlier studies elsewhere indicate that delays in accessing appropriate care are of paramount importance in explaining why a woman died or survived [
7,
8]. For Kinshasa, there is little information on the circumstances around maternal deaths. Although, part of the answer may relate to the cost and the quality of the care provided, exploring the barriers to accessing appropriate hospital care from the women's viewpoint is necessary to complete the picture.
The objective of this paper is to report the circumstances around the occurrence of complications that lead to death or near-miss, drawing on the testimonies of women who survived a serious complication, and of families of women who passed away.
Results
The interviews with surviving women and the families of those who died from their complication showed three main problems in accessing life saving interventions: delay in seeking care when needed (1
st delay according to Thaddeus & Maine [
7]), delay in obtaining/receiving appropriate care when in hospital (3
rd delay) and inadequate provision of care.
1. Delay in seeking care
All the women included in our study reached a hospital at some point in the development of their obstetric complication. Some women had already experienced a complication during their pregnancy (32% of the deceased women and 51% of the surviving ones). Among the 318 families interviewed, we identified 136 women (100 surviving and 36 deceased) who had experienced symptoms (danger signs) during their pregnancy. The vast majority (89%) decided to seek medical help or self-medicated (no difference between the two groups).
Some used traditional medicine when modern medicine failed: "Pregnancy was normal until the 7
th
month. One day, she complained of abdominal pain with fever and coughing. I accompanied her to the nearby health centre. After 4 days she became pale and her eyes yellowish. I informed my stepmother about the situation and she suggested me to find someone who could heal her with traditional medicine. However, after 4 days, the additional traditional treatment did not improve the situation, on the contrary. Then, my stepmother and I, we went to the closest maternity unit and the nurses transferred her to the referral hospital..." (ID2026, deceased woman, 27 years, parity 0, interview with her husband).
Some women (11%) did not seek treatment, although they identified alarming symptoms during their pregnancy. They were not aware of being pregnant or neglected the danger signs. "Pregnancy progressed with problems such as abdominal pain and vaginal bleeding until the 6
th
month. I did not seek care because I thought these were menstruations and I did not think I was pregnant. The haemorrhage stopped spontaneously. Then, I noticed I was weak and I could not put up with the smell. I went to a polyclinic to be examined because it looked like a pregnancy. I was told it was indeed a 6 month pregnancy and I waited for one month more before attending antenatal care." (ID1057, surviving woman, 28 years, parity 2).
Even when the complication was very obvious, some women (5 deceased and 10 surviving women) hesitated before going to the hospital. Bleeding and leaking of the amniotic fluid were not considered as danger signs, presumably because these symptoms are not painful or because the women found the quantity too small. This lack of knowledge contributed to underestimating the gravity of the complication. "I was transferred to the intensive care unit because I bled a lot... During the pregnancy I also bled, however I found it not enough to tell the doctor about..." (ID1154, surviving woman, 29 years, parity 2). The same behaviour occurred in case of amniotic fluid leaking; the persistence of the symptoms however contributed to the decision eventually to seek care. "Three weeks before the expected date of delivery, I felt the leaking of liquid between my legs. However, it was not painful and I remained hopeful for one week with the leakage. As it continued, I consulted my physician who diagnosed it as amniotic fluid leakage. Because it was urgent, I accepted a third caesarean. The baby was born alive..." (ID1199, surviving woman, 38 years, parity 4).
Lack of money is another obstacle for seeking health care, even when women are confronted with an obstetric emergency. Nine women (4 surviving and 5 deceased) tried to avoid a caesarean section because they could not afford it. They went to a health facility that clearly could not provide the care they needed or tried to deliver at home. Family often encouraged this decision. "She had twins and the course of the pregnancy was normal except that one foetus was in the transverse lie. At the last antenatal care visit, the doctor told her: whether you feel pain or not, you must go to the hospital the day of the expected delivery date. The day came and went, but she preferred to go to church and pray with the hope of a normal delivery. When she started labour, she went to the nearby health centre... Arrived around 1:00 pm, she died soon after, waiting for money to pay for the caesarean." (ID2049, deceased woman, 36 years, parity 2, interview with her mother). Or this other witness: "Around 7:00 pm, I noticed a copious vaginal haemorrhage. I spoke to my husband who told me to wait, reassuring me it would stop. I changed five times my sanitary towel and I began to feel dizzy. Then he accompanied me to the nearby health centre, it was noon... the nurse said we had to go to the hospital because it was a case requiring a caesarean section. I was not convinced and went to another health centre where I was told the same. Then, I went to the referral hospital around 11:00 pm." (ID1057, surviving woman, 28 years, parity 2).
2. Delay in obtaining hospital care
Money is a major obstacle to accessing emergency care. Sixty-one women (30 surviving and 31 deceased) were asked to pay before receiving any care. Ten died while family members were trying to gather the required cash (100 to 200 US$). "She suffered from a major haemorrhage and we brought her to the medical centre and from there she was transferred to the referral hospital. The doctor told us she needed a caesarean section. Her husband left to look for money. As the bleeding continued, she died before a caesarean section was performed, with the twins still in her womb... if the caesarean had been performed, she would not have died" (ID2074 deceased woman, 37 years, parity 6, interview with her stepmother).
Occasionally, treatment was provided before the full amount of money was handed over (n = 3, unfortunately too late for one of them). One mother had to wait more than 10 hours before the intervention, waiting for money: "... I arrived at the referral hospital at exactly 8:00 am. I was admitted to the delivery room and after an examination, the doctor told me I had to pay 46,000CF (102US$) before the treatment. Then I was left alone the whole day. When my husband brought 30,000CF (67US$), he agreed to start the treatment. Surgery began around 7:00 pm..." (ID1055, surviving woman, 46 years, parity 4). Another was lucky: "... One day, I felt a little pain the whole night, then the next day around 6:00 pm I started to bleed... When I arrived at the maternity unit, I was examined and transferred to the referral hospital. We went there around 8:00 pm. After the examination, I was asked to bring enough cash for the caesarean. I spent the whole night and the next day over there, still bleeding. I was given injections to stop the bleeding. Suddenly there was heavy bleeding and the intervention was immediately performed around 5:00 pm". (ID1061, surviving woman, 33 years parity 2).
Sometimes women's families had to resort to violence to get emergency care or to threaten the health personnel to receive care without giving an advance. "When I arrived there, I was asked for 200US$ before admission. The soldiers who had brought me threatened the staff that they would open fire if they refused to take care of me. They were afraid and they obeyed..." (ID1193, surviving woman, 37 years, parity 4).
The exact delay time between arrival and the appropriate intervention is known for only 89 cases (73 surviving and 16 deceased women). A proportion of 85% of surviving versus 44% of deceased women got the appropriate intervention within 24 hours, 40% versus 19% within 2 hours. The delay in getting care also affected the baby's chances of survival: 33% of newborns were stillborn or died before discharge if their mothers survived while 55% of newborns died if their mothers died.
3. Inappropriate hospital provision of care
We consider hospital care inadequate when there is a lack of equipment, blood, oxygen or drugs, or when the competence of the staff or their attitude is questioned.
Lack of blood has been the main factor involved in the death of 9 women. Hospital staff usually asks the family to buy blood in centres where blood is (supposedly) available. This takes time, sometimes too much time: "they transferred the woman to the referral hospital where a caesarean section was performed around 3:00 am. The baby was stillborn. They prescribed blood but there was only one unit left in the hospital. The husband went looking for blood in another hospital, however it took too much time and the woman died around 10:00 am before her husband came back with blood." (ID2090, deceased woman, 22 years, parity 2, interview with a woman's friend and a neighbour).
The availability of the operating theatre is also a problem. In the case of 2 surviving and 3 deceased women, the unavailability of the operating theatre was the cause of delay. "We arrived around 9:00 pm. I was well received but had to wait my turn before the caesarean section could be performed. The operation was performed at 2:00 am." (ID1077, surviving woman, 16 years, parity 0). And the delay is sometimes the main factor of the death: "Around 2:00 pm, the caesarean was considered urgent. However, the operation was only performed at 11:00 pm due to the numerous operations to be performed and because everyone had to wait for her turn". (ID2087, deceased woman, 23 years, parity 2, interview with the deceased's mother). Finally, the attitude of staff and their (perceived) competence are clearly important factors in the management of obstetric emergencies.
A few women expressed their gratitude to the health personnel (none of these had a financial problem), as they felt they were near-miss cases and would have died without the help of the health care staff. "Two days before the labour, my whole body was swollen. When the pains started, we went to the health centre and from there to the hospital. The doctor performed a caesarean section and I was admitted in the intensive care unit of the maternity since I was in a coma. Doctors did everything possible to save my life. My baby and I, we are alive." (ID1109, surviving woman, 19 years, parity 0). Even families of deceased women may be grateful to the hospital staff when their attitude was perceived as correct: "There was a postpartum haemorrhage following the retained placenta. Then they removed the placenta manually and she was transfused. The doctor did everything to save her. However, death came, there was nothing we could do about it, she died the same day she delivered". (ID2042, deceased woman, 34 years, parity 4, interview with her husband).
26 families did not really welcome the attitude of the staff. Women felt neglected: "the pregnancy was progressing well until the 7
th
month... Around 2:00 pm, I reached the facility where I used to attend antenatal care. I suffered from terrible backache and dizziness. My doctor was in the operating theatre. Nurses asked me to wait for him. Suddenly, I felt some liquid leaking. The nurse examined me and the cervix was only 1 cm open. Then, I started to bleed. They put me on a stretcher, waiting for the doctor. I was afraid because I had already experienced two deliveries with placenta praevia. I began to lose clots and my vision became blurred. When the doctor finished operating, the nurse did not tell him I was waiting and the doctor left. As the situation was going wrong, nurses decided to transfer me to the referral hospital" (IUD1193, surviving woman, 37 years, parity 4).
Negligence has several forms; some of them can be really hurtful. For instance, a woman with a scar infection following a caesarean section declared she was ignored by the doctor during the daily ward rounds because the caesarean was performed by another doctor. Another woman received care only from the medical students because her family was not able to pay the full amount claimed by the doctor for the caesarean section.
When a problem of organization of care is accompanied by sheer incompetence, women's lives are clearly jeopardized: "At the end of my pregnancy, the doctor wrote a transfer letter in advance and he requested pelvimetry. I have a congenital problem and my pelvis is too small. My doctor advised me to immediately go to a referral hospital as soon as the labour started. I went to the referral hospital for the pelvimetry but they charged 50US$ for this examination. As I had planned only 20US$ I went back home to try to gather the amount needed. The very same evening, I started labour and I went to the referral hospital. When I arrived there, I saw that the doctors were on strike. So I went to another referral hospital where I was told there was no room. Then, I went to hospital X. There, the doctor prescribed Theobald [oxytocic infusion] to stimulate the delivery. However, I showed the prescription where 'caesarean' was underlined. Another doctor came and read the prescription. He stopped the infusion and asked to prepare for an emergency caesarean... My 3.800kg baby was stillborn, I had a rupture of the uterus and they had to perform a hysterectomy. I got 3 bottles of blood. I woke up only the third day after the surgery/operation..." (ID1176, surviving woman, 24 years, parity 0).
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
EK created the design of the study, organized the data collection, performed statistical analysis and drafted the first manuscript in French; CG participated in the design of the study, the interpretation of data and reviewed the manuscript; VDB participated in the design of the study, the interpretation of data and wrote the English version of the manuscript. All authors read and approved the final manuscript.