A preventable curse

The next series of bogs will be coming from Uganda. I am currently based at Mulago Hospital which is the national referral hospital in the capital Kampala. During my time here I’ll be running an evaluation of the maternal high dependency unit which was set up 4 years ago by the partnership from Liverpool I’m here with. This was also a chance to brush up on my obstetrics skills (pregnancy and childbirth for the non-medics..) before starting a job in South Africa in August. UK trainees are somewhat sheltered when it comes to obstetrics and this is my chance to avoid getting egg/amniotic fluid on my face.

Helmeted guineafowl in Queen Elizabeth National Park

Helmeted guineafowl in Queen Elizabeth National Park

Childbirth is dangerous because of two major events in human evolution. I know I’ve said it in a previous blog, but I’ll say it again. Feel free to skip a paragraph.. As we evolved to walk on two legs, the female pelvis was rendered less flexible, and as we developed higher social skills larger skulls were required to house increasingly large frontal lobes. The disproportion between the inflexible pelvis and the large head means that a lot more babies get stuck on their way out into the world as you would expect. In light of this, health services in the developed world boast truly excellent obstetric services. The attention to detail on an obstetric ward is second to none, fueled by a fierce (yet performance-enhancing) medico-legal system. Ironically all this is made possible by the large cerebral cortices that make childbirth dangerous in the first place. My sister is having a baby in June and I have complete faith in the system that is caring for her. She already knows about the lie of her baby, where the placenta sits, the genetics of her baby, and when the time comes she will be surrounded by a number of highly trained professionals to see her through the process. The fact that mothers in the UK have time to choose the incense and music for the birthing process suggests that some very able people have got them covered. In this setting a maternal mortality is an anomaly, which warrants years of investigation in the rare instances it does occur.

Having a baby in Uganda however remains a dangerous business. The maternal health statistics here remain some of the worst in the world, marginally better than those I encountered in Sierra Leone. Most women have had little or no antenatal care. Most have not had their blood pressure taken, let alone an ultrasound scan. The last menstrual cycle is usually a guess and so a delivery date is hard to estimate. The population in Uganda remains largely rural so it often takes many hours to reach a healthcare facility. You hear the word ‘emergency’ more often in the world of obstetrics than any other speciality, so a journey of many hours is not just an inconvenience but a threat to life. If the risk of maternal death per pregnancy is multiplied by the fertility rate (i.e. the number of babies the average woman has) we see that a woman has a 1 in 20 chance of dying of pregnancy related problems during the course of her life.

Mulago Hospital is the tertiary referral centre for the whole of Uganda so besides seeing a large number of deliveries each year it also sees the country’s most complex cases. The unit where I am working expects to deliver 33,000 babies in any one year, compared with 8,000/year in Liverpool, one of Europe’s  busiest obstetric unit. The hospital truly is one of the beasts of African healthcare. There are 1,500 beds but probably over 3,000 patients in the hospital, not to mention the family members that are needed to deliver a large proportion of the nursing care. Supplies are critically short and there is often no supply of basic drugs or medical equipment. One nurse can expect to look after 50-80 patients, hence the need for family attendants. The entire hospital has lacked running water for the last few months due to billing issues, and there is no alcohol gel available, so infection is a serious risk. (Since writing this running water has been restored!)

Mulago Hospital

Mulago Hospital

Part of the post-natal ward

Part of the post-natal ward

The maternal pathology that presents at Mulago is nothing short of shocking. It is sometimes very tempting to blame ‘the hospital’ or the people that work within it, but the shocking pathology we see is the result of countrywide failings in health infrastructure which are in turn a result of myriad historical and political events with countless contributors. I am not exaggerating when I say that in one day we see as many of these ‘late’ and unstable conditions that a senior obstetrician in the UK may expect to see in a lifelong career. Probably the most common pathology is eclampsia. Eclampsia is the reason that midwives obsessively record a woman’s blood pressure at every antenatal appointment. As the placenta begins to age in the later stages of pregnancy, parts of the tissue begin to die and release toxins into the maternal blood stream. This is turn aggravates the inside of the mother’s blood vessels causing them to clog up, squeezing the blood volume into tighter vessels, causing the blood pressure to rise. Picked up early this can be managed with simple medications, and delivering the baby (either by inducing labour or by Caesarian section) terminates the problem. Left untreated the condition is life-threatening, both to the mother and the baby. The high pressure can disrupt the blood flow to the baby, starving the baby of oxygen in uterus, leading to a late stillbirth. The pressure will continue to rise until it causes fitting and convulsions for the mother, which has the potential for other complications as well, such as bleeding in the brain or aspiration into the lungs. The condition is completely avoidable with standard antenatal care, a blood pressure cuff, and basic obstetric services, but cases of full blown fitting eclampsia are seen here every day. Unfortunately a ‘crash’ Caesarian section (i.e. on the operating table minutes after arriving in the hospital) for a fitting mother is not always possible as the waiting time for surgery can be 8 hours or more due to the shear volume of patients, but eventually the mothers make their way to HDU for ongoing care, either with or without a baby. On Monday we received a mother from Northern Uganda who began to fit. She couldn’t be operated on for many hours and unfortunately her baby had died before she delivered. 2 days after the operation she stopped passing urine as her kidneys began to fail, and the whites of her eyes have become the deep orange of jaundice, an indication of liver damage. Red blood cells are literally torn by the aggravated lining of the blood vessels and she breathes rapidly with the anaemia. This is the severe end of the eclampsia spectrum, so called HELLP syndrome.

You can’t help feel emotionally involved when talking to the woman’s husband. A few days beforehand he was excited about the delivery of his first baby. His posture is entirely strong as he stands beside her bed. He tells me he can’t even begin to grieve for his baby until he has been there for his wife, who is thrashing around on the bed, her orange eyes wide and mad, disorientated and confused by the toxins flooding her brain. He asks me if his wife is going to survive, with complete bravery, and all I can muster is the non-committal ‘we’re doing everything we can’ line, not very bravely. Fortunately this family can afford the first round of dialysis, about $400. However the story would end there for most other mothers who at times struggle to pay for the bed sheets that they need to bring to the cover the hospital bed.

Another of the big killers here is post-natal bleeding. A huge amount of blood is supplied to the uterus, placenta and baby during pregnancy. After delivery the uterus needs to contract hard to close off all the blood vessels that have been cut. In most cases this happens successfully, but in a few the mechanism fails. This may be because the uterus is tired (it’s a muscle) after a long labour, or because part of the placenta has been torn off and trapped inside, stoping the uterus contracting down. A woman can lose a lot of blood very quickly under these circumstances. Last week we received a mother who had delivered at home and been bleeding ever since. She was still conscious but very confused and her hands and feet were cold as her body shut down the blood supply to non-essential parts of the body. It was thought that some of the placenta had been retained and she was taken to theatre for evacuation. On the ward afterwards she continued to bleed. By this point most of the clotting factors in her blood had been used up, and despite removing the offending article, the bleeding continued. This is called ‘DIC’ and is usually the end process that is very difficult to reverse. We spent hours with her squeezing in many units of blood and clotting factors but she continued to deteriorate. It’s a very distressing condition and blood begins to appear from everywhere, from each cannula/drip site, to the lips and eyes. The volume of blood lost from below makes the scene quite horrifying. Unfortunately the process had tipped over into the irreversible category and she died. This again is a completely preventable condition. Yes placenta is retained at times, in women all over the world. But the fact that this woman had delivered at home and taken many hours to reach the hospital meant that the situation was too dire by the time she reached us. She sadly left behind four children. Looking back to my time in the paediatric clinic in Sierra Leone I always noticed that the very sick children with malnutrition/TB etc were the ones who had lost their mothers for whatever reason. Lack of obstetrics services affects whole communities, not just the mothers.

If there is one thing that I have had to learn to deal with since being here it’s seeing young mothers like this die. Unfortunately this happens on a weekly basis. Having been trained in the UK I was only ever exposed to dealing with the death of older people, usually of the expected conditions of old age. (If a young person did die for any reason, the situation was handled by the most senior members of the team, the junior doctor or medical student being told to butt out.) Talking to families about death is never easy but telling a young husband, or the parents of a mother, is something different altogether. But sometimes you are surprised by the responses you get. After I told the husband about the mother I mention above he raised his hands in the air calmly and said ‘It happens Doctor’ and thanked me for our work. I’ve seen this response more often than I expected. Death here is a very apparent part of life. I don’t know whether the frequency of tragedy desensitises people, or whether there is an acceptance built on both strong traditional spiritual and modern religious beliefs (many Ugandans sign up to both). What I can tell you is that I don’t understand it and probably never will. The general impression I get is that families see these events as inevitable, that God has chosen that fate for them. Whilst this belief gives them solace, something which I would never take away from them, it’s important for us to understand that they are wrong. All of these deaths are preventable with very simple measures. When I started at Mulago hospital I was ready to blame the lack of this and lack of that on all the maternal death we saw. However having spent three months here I realise that lack of hospital care has been very little to do with the deaths that have occurred. All the mothers that have died with us had already passed the point of return before reaching the hospital doors. Obstetrics in the UK is largely about procedural skill and accuracy in the hospital setting, but in Uganda the issue remains one of community public health. Women continue to die of preventable conditions due to a lack of basic education, healthcare workers and healthcare infrastructure.

That feeling of inevitability that families feel must be the saddest thing. It is something that has been ironed out of culture in the UK as the people have realised that tragedy like this is entirely preventable. That is a culture of which we should be proud and a barometer of great successes in healthcare. My sister has now had her baby and it is an absolute pleasure to hear her talking about the process, how the doctors are bugging her, how the midwife is visiting her (yes in her own home! and there is someone called a healthcare worker who visits her in her own home too! just incredible..). The right to be overwhelmed by too much care and pampering during pregnancy and childbirth should not be confined to countries which have had a fortunate modern history. My hat goes off to all the people that are here trying to change that (I don’t count myself as one of them by the way, I’m a medical tourist compared to these martyrs). To find out more about the Liverpool-Mulago Partnership see:

www.liverpoolmulagopartnership.org

My apologies for the lack of birding photos recently. Many thanks to Henry Tufton for the use of his perv lens to capture a few of these critters on my travels:

Uganda's national bird - the grey crested crane - posing for us on a rock

Uganda’s national bird – the grey crested crane – posing for us on a rock

A couple of jacarnas get a bit too close to an African spoonbill

A couple of jacarnas get a bit too close to an African spoonbill

The majestic African fish eagle

The majestic African fish eagle

A pin-tailed wydah in full breeding plumage, caught here in the first light of day

A pin-tailed wydah in full breeding plumage, caught here in the first light of day

The wattled lapwing

The wattled lapwing

 

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