Abstract
Rationale for the Study: The Gambia is a small West African state of about 10,680 square kilometers with a population of just over 1.2 million inhabitants. It is a densely populated country with approximately 97 people per square kilometer. The Gambia depends largely on agriculture, trade and tourism for her economy. It is ranked among the poorest countries in the world with a Gross Domestic Product (GDP) of US $340. The Gambian government considers health as a key pillar to development and spending on the health
sector has increased substantially over the years. The health share of the recurrent expenditure rose from 11.5% in 1998 to 13.6% in 2001 and in the same period public health expenditure as a proportion
of GDP also rose from 1.7% to 3.3%. Access to health facilities is good with over 85% of the population living within 3 kilometers of a primary health care or outreach health post and 97% of the population
within 5 kilometers. Levels of maternal mortality in the Gambia are unacceptably high estimated at 1,050 per 100,000 live births. Medical causes of maternal deaths are well documented. However, little attention is paid on the contributing factors to maternal deaths in the country. In an effort to prevent maternal deaths in the
Gambia it is necessary to look at contributing factors, also known as “avoidable factors”.
Objectives: To identify and describe the socio-cultural, economic and health service factors contributing to maternal deaths.
Materials and Methods: A retrospective population-based study combining both qualitative and quantitative methods was used. Verbal autopsy and confidential inquiry techniques were utilized
reviewing all maternal death cases that occurred in Upper and Central River Divisions of the Gambia between January to September 2002. Each case was reviewed following the “road to maternal death”
concept. In all the cases the health records were retrieved and reviewed. Verbal autopsy was also performed on the majority of maternal deaths identified. Three reviewers performed independent
classification of cause of death and contributing factors to these deaths. A descriptive analysis of the data was made and was presented in two separate papers: quantitative and qualitative.
Results: A total of 42 maternal deaths were identified. Of these, 39 died at the referral hospital, one at a major health center, one on the road to the hospital and another one at home. In the same
corresponding period a total of 876 live births were recorded at the hospital. This gives a hospital-based maternal mortality ratio of 4,452 per 100,000 live births. Direct obstetrical deaths accounted for 28 (67%) of the cases. Hemorrhage was the most prominent cause of death accounting for 10 of the cases. Fourteen of the cases were indirect obstetric deaths. Anemia accounted for 12 out of those 14 deaths. All the cases identified contacted or were in contact with the health system when the obstetrical complication developed.
Substandard health care for obstetrical referrals, low quality primary health care, obstructions in receiving urgent care and delay in reaching a medical facility were identified as contributing factors to these deaths. Verbal autopsy was performed in 32 cases. Applying the Three Delay Model in the analysis of the qualitative data generated from the key informants indicated a delayed decision to seek medical care in 7 of the cases. Twenty-seven in 32 of the women had delay in reaching an appropriate obstetric care facility once the decision to seek care was made. However, even after reaching an appropriate obstetric care facility, 31 out of the 32 cases had not received the obstetric care services they needed. Looking at
the phases of delay cases, 7 of the 32 cases had all three delays; 21 in 32 experienced two phases of delays and 3 experienced only one type of delay. In only one case no delay could be associated with
the death.
Conclusion: Health service factors were the most frequently identified contributing factors to maternal deaths in this study. It is therefore believed that improving the quality of and accessibility to emergency obstetrical care services will significantly contribute to the reduction of maternal deaths in the area.
Keywords: Maternal mortality, Three Delay Model, Emergency obstetric care, Verbal autopsy,
contributing factors, Underlying causes, Road to death, The Gambia