Joy of motherhood - a death trap? A must read

This post was sent to me by a colleague and i was confused what title to give to it. I hope the caption is above suits it after reading. if not give me alternative title / caption.

During an Obs and Gynae call recently, I was in the labour room and there was a woman who was about to deliver for the first time, what we call a primigravida. She was fully dilated but was fine; so, I left her with the midwife to review other women. From the other room, I heard, “Push! Push!” After a few seconds, I heard the cry of a baby. We have a new mother. But for her, it was not over yet. Because it wasn’t up to five minutes after that my attention was brought to her. I went straight to see her.

She was bleeding! And there was fear in her eyes. “Doctor, what is happening to me?”, she asked. I told her she was bleeding. I could see the apprehension mounting. “Will I be okay?”, she asked, again. I said I was going to take a look. With the midwife’s assistance, I examined her and discovered she had lacerated her cervix. This occurs usually when a woman pushes before she is fully dilated. I told my patient what I had found. I reassured her she would be okay if it was repaired. With oxytocin infusion on and a good light I repaired her torn cervix. The bleeding stopped. A thought then came to me, and I asked the midwife: “Suppose this had occurred in a remote village?” And she chillily answered, “That’s all!

We once advised a mother of six who was expecting her seventh child that after her delivery she must attend the family planning clinic and on no account should she deliver elsewhere because she had the risk of bleeding. Yet, she was rushed into the emergency room a day after her last antenatal clinic in shock. She had delivered in an undisclosed place. She had utrine atony where the uterus was now lax from child bearing and could not contract to prevent bleeding. She was lucky to survive.

A common reaction when you tell a woman it is safer for her to deliver through caesarian section is, “I reject it”, or, “It is not my portion”. When they leave, it is to their pastors, or to a traditional birth attendant. Yet, they come back to us with life-threatening complications. Still, some go doctor-hopping and end up in the hands of quacks. A particular woman was counselled on the need for a caesarean section because she had had two previous C-sections. She never came as scheduled. But she did show up eventually―as a BID (Brought in Dead). She had taken her case to her pastor and remained with the praying house for about three days until her condition changed. Some women hide facts from their doctors to avoid operations. One woman connived with her nurse husband not to disclose the fact that she has had two previous C-sections. It was while the woman laboured that his conscience would not let him. She was rushed into the operating theatre eventually. Postoperative finding showed she had a ‘silent’ uterine rupture, which could have got worse.

Every day, approximately 800 women die from pregnancy and childbirth-related conditions. According to the World Health Organisation, severe bleeding (mostly bleeding after childbirth), infections (usually after childbirth) and high blood pressure during pregnancy (pre-eclampsia and eclampsia) are the major complications that contribute to mortality.

According to a landmark series of papers in the Lancet, making sure women throughout the world can give birth in a health facility in the presence of a midwife is the best strategy for substantially reducing maternal mortality.

But in Nigeria where one in 13 women die of childbirth, making it one of the highest in the world, a combination of poverty, blind faith, poor infrastructure, intractable ignorance and a dysfunctional healthcare system has continued to make sure maternal mortality figures have remained high. In the north particularly, women start to bear children early and they stop late. Even those with fewer children, it may not be deliberate. They might just be the ones spared by its other evil twin called childhood killer diseases. Many births occur under the watch of the older women who still insist that the younger ones deliver at home. Many live very far from health facilities and are too poor to transport themselves to the place. Poverty and maternal ill-health run a vicious circle as you need a well-nourished and healthy mother to go through labour successfully and to deliver a healthy baby.

Many women, especially the uneducated, prefer to be delivered by traditional birth attendants. But these TBAs have contributed significantly to maternal deaths. They are uneducated and have many traditional practices that endanger the lives of mother and baby. They take up high risk cases. And only remember the hospitals when things go awry.

Even more saddening is that women who attend antenatal care at big government referral centres do die from preventable causes. Some referral centres are stretched thin, while many are underutilised. When a surgical list has been made for women scheduled for elective caesarian section, emergencies can come in which are given greater attention. It was reported that in a federal teaching

hospital in Lagos, a woman and her baby died in a similar circumstance. When her case came up, an emergency came too which needed to be operated on urgently and unfortunately for her too, all the operating rooms were in use. The woman eventually delivered vaginally, but for reasons not yet known, both mother and baby died. Normally, when you are full, you can refer to sister hospitals. But often it takes luck not to find those other hospitals in a similar situation as your institution. Most of these big hospitals are no longer working as referral centres but like primary health centres and charging fees that can startle many high end private hospitals and they are crammed by people of higher socio-economic group. The poor are crowded out. And even when they make it there, it is a common sight to see them begging for money for treatment in the hospital or for their bills to be waived. Some cannot go home with their new born babies weeks after putting to bed because of unsettled bills. While waiting for a miracle, mosquitoes make a feast of mother and baby.

Pregnancy is not a disease, but it is a risk. Maternal mortality will not come down if every pregnant woman is seen by a doctor. It is this erroneous thinking that has partly congested many government hospitals. Skilled midwives should see women who come for ANC, and only high risk patients and those who have complaints need to see a doctor. This reduces waiting time. Also, women who do not have high risks should be directed to deliver at their nearest primary health care centre to decongest the referral centres and better care, time and attention can be given to those who really need them.

Universal health coverage through the National Health Insurance Scheme should be made mandatory. Every woman should be able to access health care. Primary health care centres must be functional and a proper referral system put in place. Private hospitals and government should work out collaboration for a win-win situation. TBAs must accept best practices and must undergo regular training. They must know their limits and must not manage high risk patients. Poverty and illiteracy remain a drawback. Women must do away with prejudices and beliefs that are detrimental to their health. They should listen to their doctors and nurses, in their best interest! The fight against high maternal mortality is one that we all must join hands to win.

•Dr. Odoemena, a medical practitioner based in Lagos, wrote in via cuzdetriumph@yahoo.co.uk