Delay in receiving care

4.4.1.3 Delay in receiving care

Failures of the health care delivery system have been identified as a major contributing factor to maternal mortality and newborn death (Akum 2013:1-9; Riaz et al 2015:279-284; Nigussie, Hailemariam & Mitike 2004:145-152; Kowalewski et al 2000:100-109;

Wilunda et al 2014:1-12; Thaddeus and Maine 1994:1091-1110). Delays in the delivery of care are good indicative of the inadequacy in the health care delivery system.

Inadequacy may be due to one or a chain of shortage of supplies, equipment, lack of trained personnel, and incompetence of the available staff.

Participants were asked about the time (delay) it took to receive prompt and appropriate care after reaching the health facility. Of the 93 deceased maternal cases and 185 mothers of the deceased newborn babies’ cases almost all had experienced some level of delay in receiving prompt and adequate obstetric care. Surprisingly, more than 90 percent of the mothers received care after an hour of reaching the health facility. And more strikingly, one out of four mothers (maternal cases) and one out of three mothers

of deceased newborn cases responded that it took them more than six hours to receive care. Generally, on average it was found to take a pregnant woman about five hours before they receive appropriate care but after reaching health facilities.

Table 4.22: Delay in receiving care at health facility

Maternal cases Mothers of deceased newborn

Receiving care F¹ F¹X¹ X¹ % F² X² F²X² %

Within half an hour 1 30 30 1.07 0 0 0 0

Half an hour to one hour 4 45 180 4.30 9 45 405 4.86

one to six hours 62 240 14880 66.67 107 240 25680 57.84 More than six hours 26 480 12480 27.96 69 480 33120 37.30

Total 93 27570 100.00 185 59205 100.00

Mean = Ʃfx¹ = 27,570 Mean = Ʃfx¹ = 59,205 N 93 N 185 =297minutees = 320 minutes = 4.57 hrs = 5.20 hrs

When other obstacles are overcome and a pregnant women and/or her newborn baby with complications reached an obstetrical care medical facility, there may be other problems that threaten their chances of survival. The challenge of receiving prompt and appropriate care after reaching the health facility may start just at the entrance. The dismal story of a 19 years old mother with her first delivery may illuminate the situation.

Her delivery was presumed to be normal as she was receiving ANC services from health extension worker. But while she was about eight months pregnant she went into labour, which lasted less than two hours. As the gestation was unexpected, she was not taken to health facility. With the assistance of her friends and neighbours, she gave birth to a baby girl at home who cried rowdily. However, the baby had very low birth weight (about 1 kg) and was cold. She was rushed to the public hospital near their village. Unfortunately the hospital was going through routine cleaning, and only the mother was able to enter the hospital while the baby hold by her older sister was stopped by the security guard outside. The family pleaded with the security guards to let the baby in, however, they didn't up until the cleaning is finished. Due to the delay in the treatment, the baby expired. The baby died due to delay by the hospital's security personnel. Physicians diagnosed the cause of death as 'low birth weight' and 'prematurity related'.

The availability of electricity and water are critical for the delivery of health services, the quality and safety of patient care, as well as provider safety. Key operational issue

mentioned in the testimonies was lack and/or termination of power and water supply.

This affected not only operations but also prevented the laboratory from functioning. An obstetrician explained:

“the mother came to the hospital with uterine ruptured. She was in critical condition and need operation, immediately. unluckily, no electric the whole day and the backup generator is also not working. Besides, our water system depends on the electric supply. Late afternoon (eight hours later), they fix the generator but we couldn't save both the mother and the baby.”

In a national survey five years prior to this study, significant portion (16%) of health centres and some hospitals in Ethiopia has no electric and water supply at all (FMoH 2009b:75-76). However, the situation of unavailability and interruption of supply doesn't appear to get better.

The other cause of considerable delay in receiving prompt and appropriate care after reaching the hospitals, more often mentioned in the testimonies, was related with lack of blood at the hospital blood bank. In Ethiopia, the majority of the hospitals are not yet backed up with standard blood banks (Berhan & Berhan 2014a:105-117). In fact, the issue of blood transfusion in Ethiopia goes beyond establishing the blood bank. It is known that although there are no blood banks around the majority of the hospitals outside Addis, several hospitals have organised a mini blood bank in their laboratory rooms, or blood donation and transfusion may be possible on demand base. The big challenge commonly encountered includes inadequate supplies and transport, lack of blood donors, the unwillingness of relatives to donate blood and inability to afford blood were the major reasons for lack of emergency blood transfusions which entails delay in receiving prompt and appropriate care after reaching the hospitals. From the testimonies of husband of a deceased mother:

"The doctor told me to find two units of blood for my wife. I donated one bottle and I couldn't find anyone here (town) to donate blood. They introduce to me a young man and he asked me ETB 2,000 (about USD100) which I can't afford.

Finally, I called her bother (110 km away) to come and donate. When he arrived the blood bags were finished and we have to wait until they get it. After giving her the blood, the doctor told us to get another two units. I went to sell one of our cow. But I learned that she couldn't make it.”

In a 7-year cohort study in a Southern Nations and Nationalities Peoples (SNNP) University Hospital in Ethiopia revealed that the proportion of overall severe anemia increased from about 28% on admission to 41% at discharge (Crane et al 2000:101-105), which showed inadequate blood transfusion due to inadequate blood in the bank.

Unlike reports from other countries, in this study there were 50% perinatal deaths (38%

stillbirth) due to inadequate blood transfusion. Perhaps, this is a good example of how fatal obstetric haemorrhage problems are and how severely compromised the obstetric management is due to the delay in even after arrival. It has shown how challenging blood transfusion is due to incapacitated blood transfusion setting in the hospital. In other words, if the central referral and a university hospital in the Southern Region is as such incapacitated, it is easy to imagine the situation in the district and zonal hospitals.