Mothers and Babies

The last ten days have been memorable for two reasons: first, in the aftermath of Dr. Serrem's appendectomy, a lot of call (4 of the last 5 nights, so I can be off this weekend); and second, some challenging cases on the maternity ward.

Ten days ago we had unexpected twins, born more than two months premature. We were able in the middle of the night to figure out the modern-appearing incubator (it appeared to have never been used) and, after a rough first night as they struggled to breath, both seemed to settle down and by the next day had begun breastfeeding. I was hopeful that they would both survive, but on the third day, the smaller one developed massive bleeding and quickly succumbed. She probably died because in all the excitement with the incubator, the midwife neglected to give a shot of Vitamin K (routine around the world) and, as preemies are prone to do, developed hemorrhagic disease of the newborn. I had not seen this in my 30 years in medicine. The second twin received her shot belatedly, and went home apparently doing well.

A week ago tonight (was it only a week ago? See last post...) I was up with first one and then a second c-section, both came in from home with obstructed labor of many hours duration.

But the most challenging was still to come. Late Sunday we admitted Christine, a woman who had a six year old at home, but had lost her second pregnancy at 7 months with an eclamptic seizure (the most severe form of toxemia). Now, still several weeks from her due date, she had been found at a dispensary to have high blood pressure and all the other signs of recurrent toxemia, and been instructed to go immediately to the District Hospital. Instead, she waited five days, and then came to Lugulu.

I worried about how small her baby was, and wanted to see if her blood pressure would settle down overnight. She had had two previous c-sections, so would need a third, and her husband was making noises from afar that it was too expensive here and he wanted her to go to the District Hospital.

By the next morning her blood pressure was worse, and she was having signs of an impending seizure. What had been concerning had now become a life-threatening emergency, but we managed to do what was necessary in a relatively expeditious manner: hydrazine for her blood pressure, magnesium injections to prevent a seizure, and (once her husband agreed) preparation for surgery. Amidst all this excitement, the nurse announced that no one had heard the baby's heart beat for two hours. Although we don't like doing a cesarean when the baby is dead, in this case I felt it gave the best chance for the mother to survive.

At surgery, the baby was limp and blue, but I thought I detected a weak pulse in the cord. I passed her off to the resuscitation nurse and concentrated on finishing the surgery. But five minutes later, from the far corner, the baby let out a lusty cry. God is good, and life is very resilient.

The mother's toxemia resolved quickly after delivery, and somehow that scrawny baby (severely growth restricted because of the mother's high blood pressure) has started to feed and appears to have a fighting chance to survive.

Later that morning, another woman came from home, with a retained placenta and post-partum hemorrhage. I discovered we had only a half unit of O+ blood in the hospital, and she was third in line, behind a man with acute leukemia who probably had less than two weeks to live, and a man with advanced HIV, to weak from anemia to even stand. I started asking some questions about how it was that we could be out of blood. It seems that a couple of years ago blood banking was regionalized, so that all our blood comes from Eldoret, an hour and a half away. (The old system was that if you received blood from our blood bank, you couldn't leave the hospital until one of your relatives donated a replacement unit. It was quite effective.) In theory, regionalization is a good idea, but it turns out that the regional blood bank relies on blood drives at colleges and secondary schools. So, three times a year, when all the schools are on vacation, we run out of blood for two or three weeks at a time.

So, some statistics. Of all the measures of health we have (infant mortality, life expectancy, etc.), the one that shows the greatest gulf between the developed world and places like Africa is maternal mortality. Infant mortality is about 20-fold higher here than in the U.S., but maternal mortality is probably a hundred-fold higher. We used to say that 500,000 women a year died of the kind of pregnancy and childbirth complications that I have described (about one per minute). Very recently, there has been a report suggesting substantial progress over the last couple of years in decreasing that number. The key to continued progress are things like better access to timely c-sections, availability of blood for transfusion, and attendance of trained medical personnel at births (usually midwives). We know here in our local area (based on a demographic survey of 70,000) that 72% of births are at home, almost all without any trained attendant. So what we see here at the hospital are the complications of those home births.

The World Health Organization has made one of its major "millennium goals" the reduction of maternal deaths by two thirds, by 2015. Until this recent report, there had been little evidence of progress, and we still have a long way to go. Pray for all the mothers around the world who face the daunting prospect of giving birth in a system where their basic needs are so often unmet; and pray that governments around the world may see their way clear to dedicate the needed resources, so that they may build on this initial progress.