Introduction

The Tenth of the International Classification of Diseases (ICD-10) defines a maternal death as the death of a woman pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes (1).

Maternal Mortality during childbirth is one of the most concerned attention of health authority in the world because it is linked with economic situation of the mother health care standard in the society and the accessibility of the mother to proper health authority during pregnancy and birth. The mother who die during pregnancy is a healthy mother and her death is very tragic because it changes an occasion which is supposed to be a happy one into a tragic occasion affecting the child and the mother in one hand and the family member in the other because the family will be disrupted , the young child or children left by the mother would suffer from malnutrition, sickness and death. The father would lead unsettled life (2).

Medical authorities classify the causes of maternal death according to the following classification:

Direct causes: about (80%)

• Haemorrhag

• Sepsis

• Hypertensive disorders of pregnancy, particularly eclampsia

• Prolonged or obstructed labor

• Complications of unsafe abortion

Indirect causes: about (20%) pre-existing conditions that are exacerbated by pregnancy or its management, like anemia, malaria, hepatitis, heart diseases, and, increasingly in some settings, HIV/AIDS(1).

The low social and economic status of girls and women is a fundamental determinant of maternal mortality in many Islamic and Arabic countries(1).

In this case report legal study they are examining a typical case of maternal mortality in a hospital in Arabic city. The purpose is to show how social health and legal factor interact.

Even in the old days of Hammurabi’s Code covering the human right and right of patient to get compensation for malpractice still modern society can’t control that (3).

Case Study

A married woman in Arabic City, whose 24 years, had 3 children which were given birth naturally with vaginal birth. She was pregnant with her 4th child, on the day of the birth her husband took her to a private hospital. She needed a caesarean section to deliver the baby safely. The anesthesiologist wasn’t there to perform the operation. He gave the technician anesthetist the permission to administer anesthesia. Before the operation started everything was going alright, until they started. Attending physician announced to the family that the patient had sensitivity to anesthesia and they had to transfer her to another hospital because there is a possibility of intensive care for artificial ventilation and cardiovascular support. So they transferred her to another hospital and she was admitted to the O.R for further management. The cardiologist announced that she was found dead on arrival, and that she had might died on route or earlier. The anesthetist and anesthetist technician said that the patients pulse was felt as they were approaching the hospital. On the ground of this catastrophe the husband wanted to sue the doctors and the hospital but, that would entails dissection (autopsy) of the body by the coroner ,so the family split between the husband and the father who refused to have his daughter dissected. On that ground the husband instead of sue the hospital and doctors on criminal cause he had to sue as civil case. Civil code which means if the judge finds the hospital and the doctors negligent then the judge would order financial compensation, and that usually take long time of litigation and expert opinion, and at the end kind of nominal financial compensation. All the indications that the fault was in the patient and not in the hospital standard of care anesthesia transporting unstable patients to another hospital and monitoring standard and resuscitation route to the other hospital.

Discussion

The legal issues of this case are tremendously complex.

First, the real story of what happened to this woman in the hospital should be clarified by the people attending and witnessed.

The second point an experts’ opinions about this case from anesthesia and abstracts to judge the standard and regularity of the clinical course in the hospital and reach to an explanation to this sudden disaster.

Third, to see the reason of the transport and to see if the patient was alive before transport and if the ambulance transporting her was well equipped to transfer such unstable patient.

Fourth, challenging the cardiologist who examine the patient on arrival to the hospital and the record of the cardiac electric tracing (ECG).

This kind of situation will continue indefinitely and everybody will claim that he did his best to resuscitate the patient but she failed to respond. The professional bodies like the medical council has no say on that except if the special committee was formed to study this case and then again it takes time to have confidential report which isn’t released to the public. At the end the solution could take more time then tribal laws will intervene and that mean group of people of the family of the diseased woman meet another group of the doctors’ families or tribe alternatively group of the hospital’s management meet to settle this endless case financially. Maternal Mortality isn’t caused by the mother because the mother can’t make the decisions about her delivery and status of her health and whether to make caesarian section or not ,or type of anesthesia according to her progress of labor. It is medical decision and that medical decision is a cross road between many factors.

First, the economical status of the mother.

Second, if she has antenatal care or not and then the standard of the hospital and medical care level of practice.

Third, patient’s right to know the extent of her health and what is needed as part of the management of her condition.

There are crucial elements of this case. Where as the responsibility laying, if there were neglects. The extent of medical responsibilities identified. The social responsibility is well known for health care. The legal system should give everybody justice.

First, legal boundaries go into the following strata:

First, contract of treatment between the doctor and patient. When a patient goes to a doctor for consultation, he is contracting with the doctor for the best available management, and not necessary the cures or life and death. This is the civil responsibility the doctor will be asked in court about the financial compensation for any harm inflected on the patient related to the amount of responsibility and the degree of incapacity and that would be judged by the tribunal judge.

Second, criminal court (2):

The physician will be answering accusation of any crime committed as any other person in the society.

Crime as committed during his practice. Example: using unsterile equipments or careless negligent treatment.

Grave professional mistakes like illegal abortion committing homicide.

From the previous mentioned factors person can judge that this case wouldn’t reach strong conclusions through the official channels, and the real truth of what happened would never be definitely found. Only professional inference would indicate that there are major drawback of professional standard of care and substandard anesthesia and substandard resuscitation.

In Middle Eastern countries, there is no such litigation and compensation like in U.S.A (4).

Not all litigation in medical

Practice would lead to a final clear cut judgment. Professional medical bodies have supervisory powers but no judgment of real standard of care the patient receives in hospital (5-8).

Acknowledgment