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. 2018 Oct 11;18(1):396.
doi: 10.1186/s12884-018-2037-1.

Maternal mortality in the Gaza strip: a look at causes and solutions

Bettina Bӧttcher  1 , Nasser Abu-El-Noor  2 , Belal Aldabbour  3 , Fadel Naim Naim  3 , Yousef Aljeesh  2
Affiliations

Maternal mortality in the Gaza strip: a look at causes and solutions

Bettina Bӧttcher et al. BMC Pregnancy Childbirth. .

Abstract

Background: Maternal mortality is an important health indicator for the overall health of a population. This study assessed the causes and contributing factors to maternal mortality that occurred in the Gaza-Strip between July 2014 and June 2015.

Methods: This is a retrospective study that used both quantitative and qualitative data. The data were collected from available medical records, investigation reports, death certificates, and field interviews with healthcare professionals as well as families.

Results: A total of 18 maternal mortalities occurred in Gaza between 1st July 2014 and June 30th 2015. Age at time of death ranged from 18 to 44 years, with 44.4% occurring before the age of 35 years. About 22.2% were primiparous, while 55.6% were grand multiparous women. The most common causes of death were sepsis, postpartum haemorrhage, and pulmonary embolism. The most striking deficiency was very poor medical documentation which was observed in 17 cases (94%). In addition, poor communication between doctors and women and their families or among healthcare teams was noticed in nine cases (50%). These were repeatedly described by families during interviews. Further aspects surfacing in many interviews were distrust by families towards clinicians and poor understanding of health conditions by women. Other factors included socioeconomic conditions, poor antenatal attendance and the impact of the 2014 war. Low morale among medical staff was expressed by most interviewed clinicians, as well as the fear of being blamed by families and management in case of adverse events. Substandard care and lack of appropriate supervision were also found in some cases.

Conclusions: This study revealed deficiencies in maternity care, some of which were linked to the socioeconomic situation and the 2014 war. Others show poor implementation of clinical guidelines and lack of professional skills in communication and teamwork. Specialised training should be offered for clinicians in order to improve these aspects. However, the most striking deficiency was the extremely poor documentation, reflecting a lack of awareness among clinicians regarding its importance. Local policymakers should focus on systematic application of quality improvement strategies in order to achieve greater patient safety and further reductions in the maternal mortality rate.

Keywords: Clinical audit; Gaza-strip; Maternal mortality; Medical documentation; Palestine; Patient safety; Quality improvement.

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Conflict of interest statement

Ethics approval and consent to participate

No Institutional Review Board (IRB) exists at the Palestinian Ministry of Health (MoH) in the Gaza-Strip, which retains jurisdiction over providing approvals for access to medical records and medical databases owned by each individual hospital. The authorized body to provide approvals for studies that involve secondary health data as well as collection and analysis of primary data from both healthcare providers and patients is provided by the Human Resources Department at the MoH in the Gaza-Strip. Therefore, ethical approval for this study was obtained from the Human Resources Department at the MoH in the Gaza-Strip, which issues ethical and administrative approvals for studies involving patients and their families. The approvals were then presented to the administrative bodies of the local hospitals in the Gaza-Strip, which in turn gave their approval and provided the research team with access to medical records housed by the individual hospitals and the available contact information for the families of deceased women who were identified to be part of the potential sample for this study. The procedure, followed in Gaza at the time of this study, did not require approval by relatives to view the medical documentation of the deceased women. The hospitals included in this study were Al-Shifa Hospital in Gaza-City, Shuhada Al-Aqsa Hospital in Deir Al-Balah, Nasser Hopsital in Khan Younis, Al-Helal Al-Emirati Hospital in Rafah and Al-Awda Hospital in Jabalia Refugee Camp, which was the only private hospital. All approvals for this study had been obtained prior to data collection.

In addition, and before conducting the interviews with family members or healthcare providers, written consent was obtained from those who were interviewed in person, whereas verbal consent was obtained from participants who were interviewed over the phone due to family preference. This had been agreed to by the Human Resources Department of the MoH. Prior to obtaining consent, the aims of the study were explained to the participants, and they were informed that they had the right to refuse participation in the study, or to withdraw at any time without being penalized. The collected data were kept under high confidentiality and anonymity as each case was assigned a code number. The women’s confidentiality was preserved throughout the study. It was explained to participants that the data collected might be published after having been analysed at the aggregate level.

Consent for publication

All patients’ data were kept strictly confidential and anonymity was preserved throughout the research process. Consent for publication was obtained from the interviewees and the Human Resources Department at the Ministry of Health.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Causes of MMR by frequency: Infectious (n = 5), Postpartum haemorrhage (n = 4), Pulmonary embolism (n = 3), Cardiac (n = 2), Asthma (n = 2), Renal (n = 1), Stroke (n = 1)
Fig. 2
Fig. 2
Frequencies of Mortalities per Month
See this image and copyright information in PMC

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