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But speakers of other languages visit the clinic as well. We do have people on staff who can speak some of these languages. In carrying out their demanding mission, FQHCs develop partnerships or informal relationships with other health care providers. One of MedNorth collaborations is with Cape Fear Clinic, a charity care health care center in New Hanover County that also provides a range of services to the uninsured and underinsured but does not receive a federal subsidy. Because these charity care clinics charge less for a patient visit, they serve the very poorest in their communities.

To ensure that it is reaching patients who may not wish to visit the clinic itself, MedNorth partners with First Fruit Ministries, a Wilmington organization that provides food, shelter and related services to the homeless. We provide health care. In the next six months, she added, MedNorth plans to launch van service, providing transport to the clinic from First Fruit and various public housing developments.

In Brunswick County, CommWell has forged ties with several faith communities, schools and other organizations to build a supportive health care safety net.

Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited

Additionally, using traditional birth attendants also played a part in delaying the women. Obtaining medical care for women with obstetric complications begins with the local recognition of warning signs and symptoms [9]. Eleven of the 32 women had illnesses and symptoms from two days up to a month before they or their families decided to seek care at a hospital.

They tended to underestimate the severity of the problem as in the case where one woman lost the use of one side of her body for six days. Her husband stated that they delayed because neither of them thought it was serious, and that through faith she would get better. Another factor that delayed the deceased women in receiving appropriate care was seeking assistance from a traditional birth attendant TBA or delivering at home instead of deciding to go directly to a health facility. This occurred in four of the cases. Labor started during the day but she wanted to go late in the afternoon because she was afraid of the neighbor seeing her.

We walked and got to the TBA at 7 pm. The TBA was able to examine her wearing gloves. Then she was told to push. Then she was examined for the second time around 4 am when the TBA could see that the baby was not coming out. She was weak. The legs and the knees were cold so that they stopped functioning. Then the TBA phoned the husband and told him about the situation so that he could start looking for a car to hire, but it was during the early hours.

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This is a new area [where the deceased woman and husband lived] so it was difficult to find transport. It was up to am before the husband could hire the car to collect her to the hospital. When she was in the car she could not talk, she could not even drink anything. We were unable to communicate with her for the whole ride to the hospital, am. When we got to the hospital, the nurses said, 'you have brought us a dead person. In the other two cases the TBAs were summoned to assist on location due to remoteness from a health facility or urgency of need.

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When the hospital is far away, the mode of transport becomes an important determinant in how soon treatment will be received and consequently in whether the woman and or child survives [21]. For three of the 17 families with whom we conducted verbal autopsies, transportation was an obstacle.

One family lived in a densely populated area near the hospital. However, the husband still had problems locating transportation in a timely manner due to the fact that the emergency occurring at the break of dawn narration shared above, Case The other two cases lived in rural areas where they only had access to animal carts. These two women died en route to the hospital, while the former died upon arrival at the hospital. All three had difficulty locating transport in the middle of night which further delayed the women in receiving treatment. The two narrations below provide vivid accounts of the hardships faced by the women and their families while attempting to reach the nearest facilities.

She looked normal at first. Towards the afternoon around 1 pm she started complaining that she was not well. So we got prepared to go to the hospital. We are far away. So to get a bicycle, to find someone to carry her was difficult. We got a cart because she could not manage on a bike. So we got the cart when it was late in the day, around 5 pm. They had to rush to the nearby houses to borrow a torch.

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Then they saw that she was not well. Immediately the ox left and ran back home. So what are we going to do? And after a little while she died at the same spot. So they had to harness the ox on the cart and return home. There are hills and valleys on the way so the guy with the bike some times had to get off the bike and start pushing the bike while the patient was sitting on the bike, so it took time.

When they received us, they checked in the health passport book and explained to us that they would not do anything because this was a serious case. It was the ambulance that took time to arrive. We waited for a long time. The ambulance picked us up after 12 midnight. We got to X according to clinical officer at am and they received and assisted us well, but it was her heart.

Even when the women reached the facilities, they did not receive adequate treatment in a timely manner or any treatment at all. Over two thirds of the women in the study experienced some type of treatment delay. Specifically, shortages of skilled staff, inadequate clinical work ups history taking and documentation , missed diagnoses, insufficient communication among staff and to families, the denial of technical skill limitations, a lack of monitoring and attentiveness, a lack of blood, and a lack of hydralazine were all reported.

In the case below, several of the aforementioned factors were at play. The woman arrived in the labor ward during the evening with strong contractions, 1 previous scar with normal fetal heart rate but she was screaming with pain and advising us on duty, especially me myself, that she would be better if she went for a cesarean section. Around past 9 pm I gave handover to a nurse midwife technician to continue taking care of the patient since I was going for a rest for four hours and later after coming from a rest to be told that the patient had died.

Going for a lie was a problem because my colleagues who received the handover were very few to look after all the patients in labor, including the patient I was handing over… From what my colleagues told me, they said that the theater was so busy through the night. This mother was supposed to be monitored very closely, although my colleagues told me that she was monitored.

My assumption is that if she ruptured in the labor ward this means that it took some time to be noted otherwise they could have noted in the first place then probably rushed with her to caesarean section as an emergency. Nurse-Midwife Technician 2. When three of the women reached the facilities, they did not receive adequate treatment in a timely manner or any treatment at all due to concealing pertinent information and due to religion.

This occurred in cases 7, 27, and In case 7 the deceased woman was HIV positive, but because she worked as a nurse where she was also a patient she did not want her colleagues to know her status. Out of the 13 cases with a known HIV positive status, she was the only one who deliberately concealed it from medical staff.

They saw how ill she was and insisted that she take an HIV test so she could be treated appropriately but she refused up until she was referred to the tertiary hospital. During this concealment period, which was almost a month, she was not on antiretroviral therapy. In case 31, the young lady who was covered in blood was found by a distant relative.

The relative took her to the hospital the same day but she lied about being pregnant so the out patient department gave her antimalarial drugs instead of referring her to the gynecology ward. Two days later she returned and admitted to being amenorrheic for four months and attempting to induce an abortion. The findings illustrate that multiple factors conspired to delay pregnant Malawians from receiving appropriate obstetric care while simultaneously conspiring to delay healthcare facilities from providing this much needed care.

The Three Delays Model helped us piece together various factors and contextualize them in the larger picture of maternal mortality in Malawi.


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Failing to recognize the gravity of the situation which resulted in delaying the decision to seek care until it was almost too late to provide the urgently needed care has been observed in other studies [22] — [24]. With pregnancy and childbirth being natural processes that take place in a specific cultural context, a possible explanation for this delay may be that some of the women might have dismissed certain signs and symptoms as being a normal part of the journey into motherhood [25]. In Tanzania, rural women seemed to avoid going to the hospital due to different interpretations of danger signs [29].

Jansen asserted that religion, medicine and magic are closely interwoven [34]. We speculated that for a couple of the deceased women they might have preferred to deliver at the TBA because they would receive one-on-one care that is closer to their homes than going to an unfamiliar, distant hospital [13] , [27] — [29]. For the other two it was a matter of having no other choice, as observed in other studies [27] , [30] , [31].

A Woman Called: Piecing Together the Ministry Puzzle

In Malawi there are approximately TBAs and of them have been trained by the government of Malawi since [13] , [28]. Although they are not considered a part of the formal healthcare system, they fill a gap of uneven distribution of healthcare personnel, particularly in the rural areas. These were most likely with assistance from a TBA [4]. TBAs are highly esteemed in their respective communities. However, that is not enough when an obstetric complication arises. Delays such as these have been reported in other studies [23] , [26].

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The main reason why we did not observe more cases facing this challenge is perhaps because the catchment area for the hospitals is semiurban with very good, accessible roads to the hospital. Nevertheless, the physical distance and difficulty with locating transport faced by the two rural cases connote aspects of remoteness such as poor road infrastructure, poor communication between communities, poverty, limited access to information, and strong adherence to traditional values [34].

Solutions must be devised that either bring the services closer to the women or make public transport readily available and affordable.