September 2002, Vol. 8, No. 2

Reproductive Health
Maternal Deaths in the Dominican Republic Analyzed

In the Dominican Republic, 94 percent of women obtain prenatal care and 97 percent deliver in hospitals, conditions that generally bode well for maternal health. Why then, researchers asked, is the country’s maternal mortality rate so high, estimated at as many as 229 deaths per 100,000 live births? In the United States, the rate is 7.7 deaths per 100,000 live births. 

After forming a multidisciplinary assessment team and analyzing the country’s national reproductive health care program, Population Council researchers and colleagues in the Dominican Republic identified the answer: a lack of high-quality care in maternity wards. 

Filthy, understaffed labor wards 
According to the researchers’ recently published report, labor wards were crowded and dirty. In the labor ward of one of the country’s two main maternity hospitals, the team observed needles, intravenous catheters, and soiled, foul-smelling bandages littering the floors. Body fluids were also found in beds and on floors. Trash overflowed waste receptacles. Complicated births were not given necessary attention and normal cases were over-medicalized (all women were given episiotomies, for example). In many hospitals, overcrowded conditions and a lack of adequately trained attendants contributed to a higher rate of maternal death. 

The study—sponsored by the United States Agency for International Development, the Population Council, and the Dominican Republic’s Ministry of Health and Social Welfare—was designed to identify strengths, prioritize solutions to problems, and work with community, governmental, and nongovernmental representatives to improve reproductive health care. 

The investigation revealed that lower-level regional institutions, although often clean and well managed, were not prepared to handle high-risk pregnancies; complicated deliveries requiring anesthesia or blood transfusions were referred to higher-level institutions. Yet the national program lacked a formal plan to transport women from one facility to another. Although a few institutions used ambulances, in most cases women were forced to rely on public transportation or private vehicles. 

Lack of trained attendants
Physicians in lower-level regional institutions often failed to appear for work; thus untrained nurses in these hospitals would either send all women to the referral hospitals or attempt to conduct deliveries themselves, receiving only telephone instructions from physicians. 

At the larger hospitals, researchers discovered crowded conditions and a lack of adequately trained attendants. For example, in one hour of observation at a higher-level hospital, the research team witnessed 12 births. During that time the most experienced person in the delivery ward was a first-year resident with five months of service. The other eight providers were interns, medical students, and nurses. 

“In promoting safe motherhood, the conventional wisdom is that if you get the women to the hospital, you will save lives,” noted the study’s lead investigator, Suellen Miller, Population Council senior consulting associate. "In the Dominican Republic, women were doing what they were supposed to be doing to ensure a safe birth: they were going to hospitals for delivery. The physicians were the ones who failed to follow the established norms for quality care, resulting in a high rate of maternal death." 

The team made a number of recommendations for improving the situation, including enforcing attendance by physicians and other staff and adherence to accepted protocols and punishing noncompliance, so that women can safely seek care at community-level institutions rather than higher-level institutions. The findings of this report have prompted Dominican health officials to suspend offending physicians and implement other measures to decrease maternal mortality. The report can be downloaded in PDF format at: http://www.popcouncil.org/pdfs/dr_strat_assessment.pdf 

Source
Miller, Suellen, Argelia Tejada et al. 2002. “Strategic assessment of reproductive health in the Dominican Republic.” Research summary of the Expanding Contraceptive Choice project. New York: USAID, SESPAS, and Population Council.

Outside funding
United States Agency for International Development/Dominican Republic Mission

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