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 Cosmas Odoemena
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