RSS

Tag Archives: maternal death

Giving Birth in the Cordillera Mountains

It has been two years since I started attending the Regional Neonatal and Maternal Death Review in our region, the Cordilleras. I had been invited to be a panelist and as such, it is my duty to critique why such happened, and what should have been the intervention, and what could have been the possible problem that really transpired for such a death. But this forum is not only me and my fellow panelists giving our “expert opinions.” Rather, I in particular had so much learnings and realizations that makes the scenario surrounding each death very painful to accept and embrace as a health care provider. These are some of the few things I came to realize…

GEOGRAPHY

One of the problems identified in our region is the geography. Because of the mountainous terrain of Cordilleras, one pregnant woman would need to hike 45 minutes, some 1 or 2 hours from their house just to reach the road or access a vehicle that will bring them to the nearest barangay health station (BHS), or rural health unit (RHU). Imagine a pregnant woman in labor, walking this distance in between contractions, you would expect a longer time to access the road. Likewise, because of this terrain, some areas are infested with the rebels (New People’s Army) that deters them to go the the nearest health facility, no matter what stage or phase of health emergency they are already in. So if the mother is having post-partum bleeding, they will wait till sunrise before the go to the nearest BHS. And if the midwife at the RHU or BHS would not be able to address the problem, they will have to transfer the patient to the nearest district hospital, which might again take them a while to look for a vehicle that will transport them there.

Another problem that the geography poses is the lack of telecommunication network’s signal. While the nurses, barangay health workers may have mobile phones that would facilitate referral to their superiors for proper advise while patients are being transported to higher centers, the lack of communication signal deters such and thus are only addressed when the midwives or the receiving doctor in the district hospital sees the patient

LACK OF HEALTH CARE PROVIDERS

Another deterrence to full delivery of health care to every household in the rural is the lack of midwives. While there may be barangay health workers (lay people who are not necessarily midwives who can be first line to check on ailing residents), it is the midwives who supervise them and who will ultimately decide whether she can manage the scenario or refer the patient to higher institution. In one municipality alone in Ifugao with 18 barangays, they only have 5 midwives. ONLY 5 midwives. Again, consider the distances of each house, their distance from the BHS or RHU or district hospital. And they usually access these houses on foot. Midwives need to track women who are pregnant, follow them up at the RHU, refer them to higher centers if the pregnancy is high-risk, deliver their babies if unable to reach a birthing facility, follow them up to make sure the mother-baby dyad is in perfect condition, submit monthly report to their municipal health officers.

During the past administration, nurses (nurse deployment program, NDP) and doctors (doctors to the barrios, DTTB) were hired to augment this vacuum of labor force. The nurses were deployed to each barangay or two, to help and facilitate the work of the midwives. Definitely being novice in the community and public health, there are flaws and misgivings, that given more time and experience, these will eventually be addressed. Nevertheless, there was a noted decrease in the number of maternal and neonatal deaths because they were monitored.

Unfortunately, starting next year, these contractual employees will no longer have their contracts renewed, making again the workload of our midwives double, maybe triple or quadruple when the NDPs are gone. Thus a rise again in the number of maternal and neonatal deaths will not be a surprise.

LACK OF SKILLS

We the panelists are specialists and subspecialists. We talk of interventions appropriate to our settings, which is way far up compared to the birthing facilities that the NDPs, midwives and MHOs work at. For one our NDPs, who are mostly first time on the job, still lack clinical acumen to detect subtle signs of disorder in the newborn, or signs of high risk pregnancy. Thus they only become alerted when the severe complications have set in, and thus intervention would be late already. Recognition of these subtle signs and early referral would definitely make a significant difference in these conditions.

Not all midwives are skilled in performing episiotomy. Not a single midwife in the region is even skilled in performing full course of neonatal resuscitation. Even doctors at district hospitals are not specialists to correctly treat these problematic parturients and/or their babies.

CULTURE

One thing that I commonly noticed is the influence of the matriarch of the family or clan. Usually, especially in a place where the house of the parturient is far from the nearest birthing facility, a birth plan is laid out. They assign which (of the limited vehicle) will be used to transport in case she goes on labor. And after birth, how soon they will be visited by the midwive or NDP. In other instances however, the matriarch interferes and alter already the planned contingency. A first-time mother ought not to contradict what their “experienced” seniors dictate upon them. While our health workers are campaigning and encouraging health facility deliveries, some “experienced” matrons insists that their daughters deliver at home, with them helping out. Only then will they call for help when they encounter a major problem. One classic example was when a woman on her third pregnancy delivered at home, assisted by the family members. It took them several minutes attempting to deliver the placenta. And because the placenta was adherent to the uterine wall, as they were tagging the former, the uterus inverted. Only then was the midwife called. And because there was no “birth plan” it took them several hours before the parturient was brought to the hospital. There was massive hemorrhage, with the source not identified, that eventually lead to hemorrhagic shock and her death. Such useless loss of lives would have been prevented had it not been for the “usual practice” that these elder people enforced.

 

Many of these problems presented are often preventable but it takes interplay of so many factors to prevent one maternal or newborn death. Our region as a long long way to go…

 
Leave a comment

Posted by on November 29, 2016 in Deliveries, neonates, Pregnancy

 

Tags: , , , , , , , , , , , , ,

While You Were Sleeping (On Reproductive Health Issues)

“While You Were Sleeping” is a romantic comedy which tells a story of a train token collector who has a crush on a regular commuter, saves him when from being ran over by a train when muggers pushed him onto the rail track, and misinterpreted as the fiancee when he falls into coma. But while the man she has a crush on is in a deep sleep, she made the family come closer and fell in-love with her “fiance’s” brother.

In the Philippines, reproductive health bill has been proposed, and few months shy from her debut, several have happened white it was ignored since drafting.

While You Were Sleeping…

The Philippine population ballooned to a population of 101,833,938 (July 2011 est, http://www.indexmundi.com/philippines/demographics_profile.html). The estimated birth rate is at 25.34 births/1000 population. The age structure is as follows:

  • 0-14 years: 34.6% (male 17,999,279/female 17,285,040)
  • 15-64 years: 61.1% (male 31,103,967/female 31,097,203)
  • 65 years and over: 4.3% (male 1,876,805/female 2,471,644) (2011 est.)
  • According to the World Bank report, our population density on 2010 reported on 2011 was 312.78 persons per sq. km, from a previous of 307.55 on 2009. (Source: http://www.tradingeconomics.com/philippines/population-density-people-per-sq-km-wb-data.html). This is a far cry from the ideal population density of 50-100 people per sq. km.

Consequently,

  • A big fraction of the population ranked themselves poor, and this kept increasing annually. In order to survive, people resorted to odd jobs, to the extent of trading themselves just to earn a living — organ donor, drug mules, prostitutes, escorts, cybersex partners, and what have you.
  • Mothers, whose body cant take anymore the burden of successive pregnancies, have been dying and dying, at an average of 11 per day.
  • Many parents cannot afford to send their children to school. Instead, they send them begging at the street (one father even had the nerve to buy cigarettes with his child’s earnings), pimp them to pedophiles and child pornography and whatever sort, just to augment the family’s income.
  • Many parents cannot afford to feed all of their children adequately, making them malnourished and sickly. Some parents even gather leftovers from fastfood restaurants, cook and feed it to their children as “pagpag”. And there was one senator who complained why this was featured in an international news network, as if denying this will cloud the fact that it exists. Malnutrition underlies all of the disorders causing under-five children’s mortalities.
  • Many parents cannot afford life-saving vaccines not offered in government health centers, making their children contributors to the mortalities among under-five population.
  • Parents are forced to go abroad to: (1) find employment as there’s no suitable job appropriate for their skills; (2) augment the meager income of the spouse; (3) help sustain the expenses of the (super-) extended family.
  • Unwanted and unplanned pregnancy has also led to abortions. Unfortunately, some mothers have died of complications from this.

While some Filipinos opted to work abroad…

  • Some OFWs contracted HIV/AIDS and other sexually transmitted infections, brought it home and spread to their partners.
  • Children lost mother/father figure who’s supposed to guide them growing up, making some of them end up as juvenile delinquents.
  • Adolescents who were not being guided during that most important phase of their life when parental guidance is badly needed, ended up pregnant/impregnating someone, significantly increasing to 70% over a decades time, as attested by UNFPA.
  • Some priests blamed rise in incidence of teenage pregnancies to moral values breakdown. (What? Why, how did it happen this way? I thought you were the moral shepherd in the country! Does that mean, you’re not being heard by your flock, irrelevant?)
  • Husbands left in the country had been committing incestuous crimes, adultery, bigamy, etc.

While mothers are dying…

  • Their children became unattended and thus their kids ended up juvenile delinquents (paulit-ulit? E sa totoo naman kas!)
  • Daughters tend to get pregnant earlier
  • Bereaved children experienced significant decline in physical health status, increased psychological distress and even increase in alcoholic consumption. (Source:  http://www.jstor.org/stable/2096138 )

While you thought sex education is taboo and should never be introduced to young children…

  • Children are resorting online for their inquiries and sexuality. Unguided, they are already accessing pornography online. (In fact, in a related incident, a child in the US was enlisted as a sex offender for life, at age 13, even without kissing a girl or having had sex with any but by mere accessing child pornography, online.)
  • Because of peer pressure and ignorance, teenagers are experimenting, ending up getting pregnant earlier, when their physical body isn’t prepared yet. UNFPA reported that incidence of teenage pregnancy ballooned to 70% from ten years ago.
  • HIV/AIDS and STI have explosively increased from 1984 to present… (see http://www.doh.gov.ph/sites/default/files/NEC_HIV_Feb-AIDSreg2012.pdf). Philippines is one of the only 5 countries where HIV/AIDS incidence is increasing.
  • Studies revealed that age-appropriate have delayed exposure to intercourse, increased use of contraceptives at first sexual intercourse, and did not promote promiscuity. (And yet the CBCP blames loose moral values as the culprit. Wasn’t that their job in the first place? So they have slackened? Shouldn’t they be ashamed pointing fingers and passing judgements?)
These are but few of the obvious implications of “sleeping” on this important measure. The casualties of reproductive health bill non-passage and non-implementation aren’t only the mothers who died because of abortion nor complicated pregnancy. It goes beyond, it also those children less than five years old – neglected and not having cared for thoroughly, appropriately and adequately due to poverty – which emanated from…?
 
 

Tags: , , , , ,

A Mother’s Day Story – Part 1

I was a faculty of a neonatal resuscitation program provider’s course when one afternoon I received a call to attend to the delivery of a preterm baby. The mother was 34 years old, on her second pregnancy, her first being 15 years ago. She was apparently alright except for her hypertension which was at 220/110 (we call these mothers, a walking time bomb). She was admitted for control as her baby is still premature but to no avail hence the emergency cesarean section. I was hoping that the hypertensive period and the current crisis hadn’t been occurring for a long time as it may greatly affect the well being of her baby. Minutes gone, and baby finally was delivered. He was a strong 1.5-kgs 32 weeks old (6 1/2 months by layman’s counting). But he had difficulty breathing spontaneously so I had to rush him to the NICU for intensive care. I provided mechanical ventilator and administer surfactant to ease his breathing. He went fine. Meanwhile, I learned that while the mother was in the recovery room the mother had seizure creating a commotion and series of procedures to keep her up…

–o0o–  –o0o– –o0o–

Few days passed, baby was now able to breath on his own. The respirator was already discontinued. He was already being fully fed via tube, meaning no more intravenous line (commonly called “dextrose”). He was now on low flow oxygen as respiratory support, still inside an incubator.

On his 10th day of life, baby suddenly crashed — his color was turning purplish, he was not breathing, the monitor indicated his blood oxygen saturation is low, and his heart has fallen below the normal. Suddenly, the nurse went to his rescue. She immediately provided bag-mask ventilation. Slowly, baby’s heart rate increase, he was turning pink back again and he resumed his breathing. While doing so, his mother was beside him, watching, caressing his head. 

Image

(photo credit: http://www.rch.org.au/paed_trauma/manual.cfm?doc_id=12610)

Baby got stabilized thereafter… After about two days, similar incident happened. Baby again had near arrest (his heart beat fell to less than 60/min, bluish in color and not breathing spontaneously). Again, bag-mask ventilation was provided until he was pulled out. He regained consciousness and was crying as if he didn’t almost die. At the time the nurse was attending to him, his mother was again there providing comfort. She wasn’t talking but her facial expression said she wanted to be with her son always, caress him, comfort him, hug him, hold him, bathe him, nurse him forever. IF ONLY she could…

 –o0o– –o0o– –o0o–

At the recovery room when the mother had seizures, her BP shoot up causing rupture of blood vessels inside her head. She suffered what we call a hemorrhagic stroke (a stroke caused by hemorrhage in her brain from a rupture of blood vessels). She had to be operated on… She fell into coma… She laid there at the ICU with all the machines keeping her live… She arrested – her heartbeat stopped 10 days after she gave birth. Despite heroic measures, she didn’t make it. At that very same time she was being revived, the nurse in the NICU was reviving the baby… while the mother was caressing him…

The second time that baby was arresting, the nurse who saw mother caressing the baby while he was being resuscitated came from a leave, and had no idea that the mother passed away2 days ago …

 –o0o– –o0o– –o0o–

After discharged from the hospital, I saw baby for a few times for some vaccinations. But as days went, I noticed that baby hardly interacted. His face was becoming more and more expression-less unless he cried. He would never smile no matter how hard I try to make him. Deprived of maternal care… He was being passed from grandmother to grandmother, aunt to aunt depending on who’s free and available. This costs him inconsistencies of affection and care– something that confused his premature brain, which required consistency of maternal presence and care…

Few months more, I didn’t see baby anymore… I wonder how he is now…

As for the mother… she missed the chance of being a mother to her son. He was a vibrant boy until his emotional regression. She could have nursed him, bathed him, sent him to sleep, fed him. She could have watched him roll over, crawl, learn to stand and walk. She could have heard him say “mama” as his first word. She could have brought him to the park. She could stopped him crying. She could have… Only if death hadn’t stole him away from his son and family.

 

Tags: , , ,

Importance of Mother’s Presence to Her Preterm Baby’s Development

Image

(Photo courtesy: http://www.victorianweb.org)

Yeah yeah yeah, she is JUST a mother, and she is just as dispensable as anyone else. So what does that make her special?

Let us look at a fetus developing in a mother’s womb. Fetal development usually proceed in a cephalocaudal (head to foot) pattern. In fact, the very first organ that forms is the brain and spinal cord. As far as the fetus’ neurosensory development is concerned, it occurs in a sequential pattern, starting with

  1. tactile/skin, 7.5-18 weeks
  2. chemosensory (taste), 12-14 weeks
  3. movement and position (vestibular, kinesthetic), 20-25 weeks
  4. auditory, 24-35 weeks
  5. visual, 30wks to 24 months. [Jean-Pierre Lecanuet, Benoist Schaal, Eur J Obstet. Gynecol. Repr. Biol. 68 (1996);1-23.] 
Image

(Fetus inside its most comfortable environment at 20 weeks gestation).

The fetus gets used to the mother’s voice that he will only recognized that of the mother and no one else. This carefully orchestrated process of sensory development happens with continuous interaction with the baby’s environment, leading to baby born with a brain eager for it’s future development (Conneman, MD).

Image

(Photo courtesy: http://brownpelicanla.com/archives/90801)

(Fetus at 20 weeks: The thumb sucking and the hand touching the head/face is not coincidental. This reflects the baby’s kinesthetic development that start at this age of gestation).

What happens then when a baby gets born prematurely, say from an uncontrolled maternal hypertension, or infection of the uterus? 

When the baby get’s delivered prematurely, there is a sensory mismatch between the environment and the prematurely born infant; the environment is different from what the brain was promised for it’s development (Conneman, MD).

Image

(Photo courtesy: http://www.riversideonline.com/health_reference/Womens-Health/DS00137.cfm)

When a premature baby cries, this is a sign of or a distress call. Baby is calling for his mother to comfort him. Usually, simple cuddling of the head will appease him and eventually make him quiet.

Image

(Photo courtesy: http://www.sciencephoto.com/media/290959/enlarge)

Babies are liable to the most severe anxieties. If they are left for long unattended (such as several minutes or even hours) without familiar and human contact (the mother), they have experiences which can only be described as:

  1. going to pieces
  2. falling forever
  3. dying and dying and dying
  4. losing all vestige of hope of the renewal of contacts (DW Winnicott,Dependence in Child Care, 1970). 

Inability of the mother to attend to his call immediately will make him withdraw and then eventually lose confidence on his mother.  If this scenario is repeated, for instance maternal death, the sequela, though may seem subtle, is fatal. A nurse on duty who attends to the baby during these distress calls, will never replace the comfort provided by his own mother.

Premature not attended to by that familiar human contact (mother) will end up with

  1. cognitive impairment
  2. specific drug preferences, and
  3. poor socialization skills.

Since infants experience the world directly through their sensory systems, behavior provides an accurate mirror of the appropriateness of current experience (Conneman). BEHAVIOR is the infant’s primary means of communication.

 
Leave a comment

Posted by on April 22, 2012 in neonates, Pregnancy, RHBill

 

Tags: , ,