Stories From the Field:

Africa

Score Zero

Dr. Blair Wylie

“31 year old gravida 3 para 2. Term.  Delivery Caeser.  Score 0.”

“22 year old gravida 1 para 1 female. Term. Delivery vaginal. Score 0.”

“20 year old gravida 2 para 2. Term. Delivery Caeser. 3.1 kilos. Score 7 and 9.”

As I sat listening to morning report given by the off going obstetric resident on the labor floor of the Mbarara Regional Referral Hospital (MRRH) in southwest Uganda, the significance of ‘score zero’ finally dawned on me.  Residents were recounting the well-known Apgar score designed to quickly summarize the health of a newborn at the time of delivery.  ‘Score zero’ meant no signs of life. A stillbirth.  I scanned the faces in the room as morning report continued.  Did they hear what I heard? Several additional score zeros were awarded. In two days of morning report, I went on to count 9 stillbirths and 2 additional neonatal deaths that occurred in the delivery room. I think I missed a few before I started counting.  The resident running morning report did not skip a beat, moving on to summarize the next delivery. The faculty did not interrupt to ask for details of the death.  There were just too many.

Just ten days prior, as the attending maternal-fetal medicine specialist responsible for the health of high risk pregnant mothers on the antepartum service at Mass General Hospital in Boston, I had received a dreaded middle of the night page from the nurse on the floor.  Mrs. A, a woman whom we had hospitalized for severe, early-onset preeclampsia for close maternal and fetal monitoring, had called out to say she was not feeling well.  The baby’s heart rate could not be found.  An ultrasound confirmed that the baby had died.  A stillbirth.  In the hospital.  On our watch.  As I stood outside her room trying to gather my composure, I ultimately decided to let her see my tears fall.  This is a luxury denied to the obstetrics residents, faculty, midwives and perhaps even mothers in Uganda.  Pausing to grieve the loss of a fetus or newborn is just not possible.  Too many other mothers need their help. 

Approximately 8,000 deliveries occur at the MRRH each year, about 20 per day. Attending to these deliveries are two resident obstetricians in-training and 1 to 2 midwives.  There are no obstetric nurses.  The faculty physician assigned to the hospital is often tied up with other academic responsibilities, available primarily for complicated cases. The patient to nurse-midwife ratio can be as high as 60 to 1.  Many deliveries in the hospital go unattended by any provider (doctor or midwife). Maternal vital signs  (blood pressure, temperature, heart rate) are recorded on arrival to the hospital.  They are rarely checked again, if at all, during labor. The fetal heart rate is rarely monitored.  A woman died, on average, during childbirth every 10-12 days during 2010.  This is improved from once approximately every 7 days the year before. There are just not enough bodies to accomplish the most basic tasks. When a decision to deliver by cesarean is made, the average time to start the operation is 120 minutes later. Family members often have to leave the hospital to purchase basic surgical supplies before the surgery can commence given the frequent stock outs at the hospital.   And this is the referral facility for the region.

As I visited Mbarara that week, I reflected on how I might fare on a 24 hour call on their labor floor. Sadly, I do not believe my decade of obstetric experience or sub-speciality training in high-risk obstetrics would have saved any of the babies or mothers.  Obstetrics is a team sport.  Gross understaffing and lack of basic supplies contributes to preventable deaths.  Innovative solutions will need to be found to help solve this complex problem. 

Since my initial visit, the Vincent Department of Obstetrics and Gynecology at Mass General Hospital has established a partnership with the Department of Obstetrics and Gynecology of Mbarara University of Science and Technology at MRRH in Uganda to address these challenges.  The partnership focuses on care to relieve suffering of women today, education to train leaders in global women’s health for tomorrow, and research to improve the lives of women for generations to come.  Stillbirths are now recorded in a dedicated database.  The hope is to identify preventable risk factors.  The simple act of recording such deaths has decreased the stillbirth rate in a matter of months.  We dream of a day when ‘score zero’ is rarely uttered during morning report.  Rare enough that mothers and providers may mourn the loss.

Dr. Blair Wylie
June 2012
Division of Maternal-Fetal Medicine
The Vincent Obstetrics & Gynecology Service
Massachusetts General Hospital