Cases of women in Kosovo that have lost their lives during or after child birth in the last decade have not been taken seriously by Kosovo’s health institutions, with a lack of accurate data leaving those possibly responsible for their deaths immune from responsibility and their families without justice.
On February 9, 2019, 42-year-old Nurije Rexhahmetaj went to the Regional Hospital in Peja to give birth to her third child. Soon after the birth, her condition became complicated. After being treated in Peja for a rupture in her uterus, she was transferred to the University Clinical Center of Kosovo, UCCK. There, Nurije passed away along with her baby, Drin, who she named while she was pregnant. She left behind two daughters, a seven-year-old and a five-year-old.
The Rexhahmetaj family, from Isniq in the Municipality of Decan, believe that the gynecologist who was overseeing Nurije’s labor is responsible for both her death and Drin’s. According to them, the doctor was well aware of the complications following the birth and should have sent her for surgery earlier.
“He made a fatal mistake as a professional,” Hajdar Rexhametaj, a lawyer and Nurije’s brother-in-law, tells BIRN. “Even though Nurije and Drin were doing well and everything seemed normal, they came back to us dead.”
Hysen Rexhahmetaj holding a framed portrait of his wife Nurije Rexhahmetaj. Photo: Shqipe Gjocaj.
The tragedy experienced by the Rexhahmetaj family is not an isolated case in Kosovo. Similar cases of deaths during or after childbirth, known as ‘maternal deaths,’ have been recorded over the last few years.
On March 29, 2019, 32-year-old Drilona Lleshi-Morina died after giving birth at UCCK. Lleshi-Morina was transferred from Gjakova Hospital to UCCK, undergoing three rounds of surgery within five days for reasons still unknown to her family.
In December 2018, Zyrafete Ademi from the village of Begaj in Vushtrri died two days after giving birth at UCCK. Her husband blames the doctors for what happened to her, believing they administered two doses of anesthetic during labor which led to her death.
As with Nurije’s case, doctors questioned by the media over the deaths of Lleshi-Morina and Ademi have denied that they are responsible, and health institutions in Kosovo failing to record these deaths accurately makes it impossible to discern whether or not someone should be held accountable.
The World Health Organization, WHO, requires health institutions to record when a preventable death occurs related to pregnancy or childbirth, known as ‘maternal death.’ The WHO defines this as the death of a woman while pregnant or within 42 days after pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.
Kosovo does not provide accurate data on maternal deaths. In 2018, according to the Kosovo Agency for Statistics, ASK, there were over 23,000 births registered in Kosovo hospitals and over 6,000 registered births of babies from Kosovo abroad, but no data whatsoever has been provided on maternal deaths. From the information provided by ASK, it appears that between 2012 and 2018, not a single maternal death in Kosovo was reported.
Furthermore, relevant health institutions in Kosovo are not claiming responsibility for recording this data. BIRN requested statistics on maternal deaths from the last ten years from the Kosovo Gynecological and Obstetric Clinic at the University Clinical Center Kosovo, UCCK, but the Clinic said that this data should be requested from the Central Intensive Care Unit of UCCK.
“The Clinic [Central Intensive Care Unit] is not in the possession of 10 years of statistics,” the media office of UCCK replied. “We recommend that you ask the Association of Obstetricians and Gynecologists of Kosovo for these statistics, because this Association has published annual reports over the years and may be in possession of this information.”
BIRN has contacted the Association of Obstetricians and Gynecologists of Kosovo on several occasions for the last ten years of statistical data on maternal deaths, but did not receive the data requested.
Illustration: Jete Dobranja.
Even finding data on maternal deaths as recently as two years ago is difficult. Shaqir Uka, Acting Chief of the Central Intensive Care Unit, said to BIRN that in 2018 there were no patients in intensive care who died as a result of “postpartum complications.” However, since January 2019, Uka confirmed that four patients have died from such complications, all occurring between February and May, who were transferred from regional hospitals in Peja, Prizren, Gjakova and Vushtrri to the intensive care unit in Prishtina.
State institutions have admitted that these numbers are not an accurate reflection of the frequency of maternal deaths in Kosovo. “Maternal deaths are lost in the system,” says Merita Vuthaj, head of the Division of Maternal and Child Health at the Ministry of Health. According to her, both the Kosovo Gynecological and Obstetric Clinic and the Central Intensive Care Unit should be providing data to the Ministry of Health on maternal deaths.
According to Vuthaj, 2009 was one of the only years that statistics on maternal deaths were recorded. Of the twelve people that died that year, three of their deaths were attributed to the swine flu virus.
Vuthaj believes that the lack of a proper information system that collates data related to maternal deaths is a serious problem. “Let us take an example: if during complications [following birth] a woman remains in a coma, and is perhaps transferred to the neurology department, she stays there for two to three months – and after that, she dies. Her death will not be registered as a maternal death, but rather death by blood loss,” said Vuthaj.
Visare Mujko-Nimani, the head of the United Nations Population Fund in Kosovo, UNFPA, says that when family members go to retrieve their loved ones after they have died, the release certificate provided that outlines cause of death never specifies that it was a maternal death.
“If the cause is maternal death, the release certificate from the health institution should include the WHO code that identifies the case as a maternal death. More information can be added on top of this – heart problems, hypertension, or other issues,” said Mujko-Nimani.
“We requested data related to the number of maternal deaths, and the Ministry of Health replied ‘none,’” she continued, adding that when working with various national health institutions in Kosovo, the UNFPA is aware of cases of women that they know by name who suffered maternal deaths and were not recorded as such.
Mujko-Nimani believes the failure of Kosovo’s health professionals to identify and record cases of maternal deaths severely aggravates any steps towards prevention of this phenomena, and the Ministry of Health continues to insist that the number of maternal deaths this year has been zero. “We know for certain it wasn’t zero,” she points out.
Accurate recording of deaths absent
On top of failing to register Nurije’s death as a maternal death, the information listed on the release certificate that the Rexhahmetaj family received from Peja Hospital does not match what the doctors involved in Nurije’s case told the family on the day she died.
“This release certificate does not give us even a quarter of the reality,” says Nurije’s brother-in-law, adding that he believes the data contained in the release certificate is just a way to camouflage and protect the colleague responsible and the institution as a whole.
Nurije’s sister-in-law, 50-year-old Fidajet Rexhahmetaj, who is now taking care of Nurije’s two daughters, believes there were other steps taken that may have contributed to Nurije’s complications after birth. According to her, Nurije’s contractions were rare, only occurring every 20-30 minutes. The doctor administered an injection to induce labor, which may have contributed to the uterine rupture that followed.
Jakup Ismajli, the head of the Kosovo Gynecological and Obstetric Clinic, told BIRN that the most common factors causing maternal death are postpartum bleeding, high blood pressure in pregnancy, postnatal infections, illegal termination of pregnancy and pulmonary embolism. Other factors include specific cases where pregnancy occurs outside the womb, known as ectopic pregnancy, uterine rupture or placenta previa, which involves complications caused by abnormal positioning of the placenta.
As the doctors were aware of Nurije’s uterine rupture and should have known already what to do in such a situation, Rexhahmetaj’s family believes that the gynecologist who was in charge of the department the night she was there as the key person responsible for Nurije’s death.
Illustration: Jete Dobranja.
“A gynecologist who is familiar with the birth process and uterine rupture should know that there is a birth room, and then there is an operating theater. Nurije should have been taken for surgery immediately; at least one of them could have been saved,” says Hajdari.
BIRN spoke to the Executive Director of the Peja General Hospital, Dr. Skender Dreshaj, and with the Director of the Gynecology Department, Dr. Saimon Loxha. Dreshaj referred to the autopsy report received from the Forensic Institute following her death, which confirmed that Nurije suffered a uterine rupture and the bleeding caused by this rupture led to her death.
Asked about the Rexhahmetaj family’s allegations, Dreshaj replied that they are ready to address any charges brought against them as an institution. “If they summon us to court, we will respond,” he said. “We will certainly defend our position.”
Loxha acknowledged that the number of maternal deaths recorded is alarming. According to him, in the 40,000 births that have taken place at the hospital in Peja between 2000 and 2018, only four maternal deaths have occurred. This would actually put the hospital in line with the European average for maternal deaths, which sits at 4 maternal deaths to every 50,000 births.
Loxha added that sometimes, maternal deaths are unavoidable. “If you go through the timeline of the 50,000 births that have occurred in our hospital since 2000, this situation is not commendable, but it means that these [maternal deaths] can happen,” he said. “And, unfortunately, it will also continue to happen.”
Vuthaj from the Ministry of Health agrees. “Mistakes happen,” she said. However, she acknowledges that when correct protocol is not followed, then those responsible should be held accountable.
According to Kosovo’s criminal law, a health professional can be held responsible for the death of a patient if they apply an “obviously inadequate means or method of medical treatment” or “obviously fail to follow the rules of the health profession or obviously act carelessly” in such a way that causes their death, they can be imprisoned for between three and 12 years.
However, this is not so easy to prove, as evidenced by the case of Arbenita Selimi-Spahiu from Gjilan, who died in March 2016 at Gjilan Regional Hospital.
Three health professionals were charged in 2016 for failing to provide adequate medical assistance to Selimi-Spahiu after she suffered hemorrhagic shock – serious blood loss – by the Serious Crimes Department at the Basic Court in Gjilan. Mexhide Shaqiri, the chief of the maternity ward, Hamide Zeqiri, a doctor at the ward and Vjollca Kosumi, a custodian doctor, were all acquitted on the grounds that the charges were not substantiated. The court concluded that it could not be proven that the medical staff refused to give her adequate treatment, not that they administered the incorrect medication. The judgement sparked civil protests in Gjilan the year after her death.
Improving prevention and accountability for maternal deaths
According to the World Health Organization, 94 per cent of all maternal deaths occur in low-income countries, and suggests that maternal deaths are preventable so long as appropriate institutional care before, during, and after birth can be provided.
The European Union is estimated to have the lowest maternal mortality rates in the world, with an average of eight deaths per 100,000 births. In countries like Finland or Sweden, that rate is even lower, with 3 or 4 deaths per 100,000 births.
Miran Vatovec, a policy officer who monitors health protection policies from a political perspective at the European Union Office in Kosovo, told BIRN that the issue of maternal deaths in Kosovo is more a matter of policy and ability to provide quality health services.
He said that the European Union Office in Kosovo and the European Commission cooperate with health authorities in Kosovo, encouraging them to take steps to improve health service provision. “We are strongly encouraging governments in Kosovo to create a public health insurance system, invest in digitizing the health system and operationalize the public health fund,” Vatovec said, adding that these issues are yet to be addressed.
Mujko-Nimani believes these problems are not likely to be solved until both men and women begin to discuss women’s health as a priority. “There are people in decision making positions who do not consider a mother’s life, or a woman’s life, worthwhile,” she said. “A lost life should mean something to us all.”
The right of access to health care and effective legal protection are rights guaranteed by the United Nations International Convention on the Elimination of All Forms of Discrimination against Women. As the only comprehensive international treaty guaranteeing women’s human rights in reproductive affairs, the convention addresses strategies for the prevention of maternal deaths and holds governments accountable for lack of access to health care, and for developing policies that routinely ignore women’s human rights.
This convention is directly applicable in Kosovo, having been written into the constitution. However, while Kosovo authorities are obliged to take this law into account when drafting law and policy related to reproductive rights, Kosovo’s lack of membership in the UN and its related agencies means that Kosovo citizens have no direct access to accountability mechanisms when their human rights are violated.
As such, for families like Nurije’s, holding individuals accountable through the Kosovo court system remains their only option.
Back in Decan, the Rexhametaj family hope that state institutions will be held accountable, and that someone will be able to shed light on the circumstances of Nurije’s death. Her brother-in-law insists that he and his family are not seeking revenge, but rather justice for Nurije and Drin and professional accountability.
“We do not want any more cases like Nurije’s to be repeated, and we want to contribute to this being achieved,” he said.
This publication has been produced with the assistance of the European Union. The contents of this publication are the sole responsibility of Shqipe Gjocaj and can in no way be taken to reflect reflect the views of the European Union or BIRN and AJK.