All mothers are vulnerable to health risks. More so during the time they are pregnant. Other factors such as age and pre-existing chronic diseases, lowered immunity that have led to lowered immune systems unable to fight diseases have put their lives on the line.
While Sri Lanka’s excellent health indices have in the recent years caused a dramatic plunge in maternal and infant morbidity and mortality, latest data has revealed that mothers and infants continue to die for various reasons, many of which are sadly, preventable, says an eminent obstetrician and gynaecologist , Dr UDP Ratnasiri, from a leading hospital for women in Colombo, The Castle Street Hospital for Women. In the following interview with the Sunday Observer, this senior specialist in women’s health gives us valuable insights why mothers die while giving birth or soon afterwards and how these deaths could be prevented . He also underscores the importance of healthy diets and lifestyles as being the cornerstone for healthy citizens of tomorrow.
Excerpts…
Q. Despite Sri Lanka’s excellent health indices and the dramatic plunge in maternal morbid and mortality rates, there is still a significant proportion of mothers who die while giving birth. The numbers cited vary. Do you have any updated figures you can give us?
A. Our percentage of institutional deliveries is 99.9%. The caesarean section rate is around 36.3%. The maternal mortality rate is 33.7 per 100,000 live births. Percentage of mothers reported with antenatal morbidity in 2016 is 32.1%. However, reporting system on maternal morbidity is still lacking in our country.
Q. At what period before delivery does a mother- to- be become vulnerable to health risks?
A. Any mother is vulnerable to health risks at any period of gestation before delivery. The gravity and the type of problems vary according to the gestation.
Q. What are the kinds of health risks commonly seen in the majority of pregnant women? (Elaborate) Are they pre-existing conditions like hypertension, heart disease , etc? Or conditions they have developed during pregnancy?
A. Most of the health risks we see in our women develop during pregnancy. Examples are anaemia, gestational diabetes mellitus, obesity, metabolic syndrome and pregnancy induced hypertension. Pre-existing conditions like heart disease is also seen in few women. Recent epidemics of influenza and dengue fever were also significant health risks for mothers.
Q. Which of the health risks you mentioned has seen a significant increase in recent years before delivery, and why?
A. Obesity, metabolic syndrome and its consequences have significantly increased in recent years, as well as mothers with pre -existing hypertension and diabetes. This may be partly due to older age of getting pregnant and change in the lifestyle. Recent epidemics of dengue and influenza also caused significant increase in maternal health risks.
Q. Some mothers develop diseases only after they get pregnant. Gestational diabetes Mellitus is one. It is said, a significant number of women carry a serious health risk at the time of delivery due to this condition. What role can an obstetrician and gynecologist like yourself, play in helping to minimize the impact of the risk that both mother and baby face?
A. We have to play a major role in both prevention and treatment of this condition to minimize the maternal and fetal risks. We can educate the mothers at risk of developing this condition.
We are screening all pregnant women at the time of the first antenatal visit and at 28 weeks of gestation. If the mother is diagnosed with gestational diabetes, multidisciplinary care should be given, including the nutritionists, physician or the endocrinologists.
Optimum blood sugar control should be achieved on an individual basis with regular frequent follow-ups. Fetal growth and well-being should be monitored regularly. This will prevent development of fetal effects. Further, the timing of the delivery should be decided by the obstetrician according to maternal and fetal conditions. At the time of the delivery, an experienced obstetrician and neonatologist should involve to prevent intrapartum complications.
After the delivery mother should be assessed further for blood sugar control and if necessary, drugs should be continued. Family planning services should be provided and they should be advised on continuing healthy lifestyle measures since they are at risk of developing diabetes in the future.
Q. What are the options that pregnant women have in such situations?
A. As treatment options they have dietary and lifestyle modifying strategies, oral hypoglycemic drugs and insulin therapy. The type of treatment depends on the blood sugar condition of the mother and the baby.
Decision on the mode of delivery and the timing should be taken by an obstetrician after discussion with the mother.
Q. Unlike in the past, today, more women opt for delivery by Caesarean section. What are the reasons? Is this a healthy trend?
A. No. this is not a healthy trend at all. Caesarean section is a major surgery and should be done only when needed. However, it has become an unhealthy trend maybe because of fears and myths of people towards normal vaginal delivery. Over medication of obstetric practice has resulted in increased caesarean section rates.The rate has gone up by 1% every year since 2011 and at present it is 33.8 %
Q. What are the benefits and disadvantages of a Caesarean section delivery as against a natural delivery?
A. There aren’t many advantages of having a Caesarean section. But in some situations, for the best interest for the mother or baby, it is necessary. Sometimes there are conditions that does not favour natural delivery, like placenta praevia. In contrast, there are many disadvantages. It is a major surgery and carries a risk of major hemorrhage, damage to other structures like the bladder and bowels, etc.
The more catastrophic of all is the nightmare of an obstetrician, on the increased risk of developing morbid adherence of placenta during subsequent pregnancies.
Q. In what instances is it necessary for an obstetrician to recommend that the mother delivers by Caesarean section?
A. Conditions not suitable for vaginal delivery like placenta praevia, transverse lie at term, some medical disorders depending on its severity and mothers who have undergone more than one Caesarean section in the past, etc.
Q. If a mother has an infectious disease such as a sexually transmitted disease like HIV/AIDS, what decision will the attending surgeon in consultation with the gynaecologist make with regard to the manner of delivery? Why? What are the risks that the mother and baby would face?
A. These mothers also need multidisciplinary involvement with the help of the venereologist, neonatologist, obstetrician and the supportive staff.
The decision of mode depends on the viral load and the condition of the mother at the time of delivery. Here, we have to consider measures to prevent mother to child transmission of the virus and the protection of the healthcare staff.
Most of the time elective Caesarean section is indicated. But, if the viral load is minimal, we can consider natural delivery, provided adequate measures are taken to prevent mother to child transmission of the virus in the intrapartum period.
Q. You are the President-elect of the Perinatal Society of Sri Lanka. Briefly remind us of the history of this society, why it was formed and what its functions are.
A. The perinatal society was established in 2001 at the Family Health Bureau. The founder president was Prof Indrajee Amarasinghe. The membership includes obstetricians, neonatologists, paediatricians and community physicians.
The objectives of the society are, promoting maternal, fetal and neonatal well being , advancing the theory and practice of perinatology, encouraging training and research, providing expert advice to government and other bodies on matters pertaining to perinatology and to maintain liaison with other organizations of professionals involved in perinatology, both, in Sri Lanka and internationally.
Q. Does caring for a mother on the part of perinatologists extend beyond the point of delivery? If so, till when? Days? Weeks? Months?
A. Yes. Perinatal period is defined as from 28 weeks of intra uterine life to 28 days after birth. But continuity of care goes on beyond.
Q. What kind of assistance does the new mother get? Where is it accessible? Only at state hospitals? Lifestyle centres?
A. Assistance is accessible to the in state hospitals in antenatal, during the time of delivery and during the postpartum period. Mother and the father are invited to attend parentcraft classes held in the hospital.
They are given lectures and demonstration on nutrition, exercises, breast feeding, baby care, about minor ailments in pregnancy, family planning, the support like pain relief and female companion, in labour. These classes are held in government hospitals as well as some private hospital.
Q. New mothers often suffer from post-traumatic stress, leading to depression and even attempts at suicide. What kind of assistance does your Society provide them? Do you have trained counsellors?
Do they also train care givers since many mothers suffer from this only after they return home and if home conditions are unfavourable. Your comments?
A. The assessment of psychological status in new mothers is not properly performed in our setup. We do not have trained counsellors. All health care givers should be able to identify mothers who are at risk of developing psychological imbalances and training programs should be promoted.
The perinatal society of Sri Lanka is going to initiate such steps to educate the midwifery staff in the community regarding this with the help of a psychiatrist in the council during my tenure as president of the society. Mothers can develop acute stress disorders, post partum psychosis or post partum depression leading to suicide.
Identification of mothers at high risk is needed to be identified during the antenatal period and necessary referrals to psychiatrist and counselors should be done and managed according to their advice.
Q. What are the new advances globally available to provide mothers with quality care during and after pregnancy?
A. Testing for fetal anomalies and fetal medicine to treat some of the conditions intrauterine and termination of pregnancy once lethal abnormalities are diagnosed. Respectful maternity care is the package for them during pregnancy and child birth. Mother should be educated about the facilities available to her and advised to request and get them whenever necessary. New and effective methods of pain relief during labour, like epidural analgesia. Keeping the husband during delivery.
Support groups and counsellors
Q. Are they available in Sri Lanka? Where?
A. Some of the diagnostic tests for the detection of fetal malformation are available in the private sector with high cost. But fetal medicine facilities are minimally available for treatment.
There is no legal support for termination of pregnancy for lethal fetal abnormalities.
Q. What are the gaps you see in our present health care programs for expectant mothers? Are there sufficient gynaecologists and obstetricians, psychologists, Psychiatrists, theatre staff labourers, operating theatres, etc?
A. There are about 300 obstetricians serving in the country both in the government and private sector. Most hospitals in the country above district hospitals are manned by two or more obstetricians and gynaecologists.
There is a substantial shortage of psychiatrist and psychologists to provide minimal care for pregnant mothers.
Lack of nursing and midwifery staff is also a significant factor for the substandard care in some situations. Adequate staff and infrastructure is a major problem we encounter to provide quality healthcare.
Lack of good quality instruments, scanners and other instruments prevent us from providing good quality care. Even with such difficulties, in many centers our staff provide maximum health care for mothers.
Q. Do you think it is a good thing to involve men (husbands and partners) in the act of birth as in some countries in the West? Most Lankan mothers lack adequate support from the family. Your comments?
A. When facilities are available, it is good to involve husbands in the act of birth as it has shown to reduce the time of labour, need of medications to alleviate pain, etc.
However, acceptance of this in our society is questionable. But, involvement of a female family member as the labour companion is a feasible alternative in our setup.
Q. How can these gaps be filled? What is the best approach to resolving them?
A. Women should be empowered during the antenatal period and their minds should be prepared for labour and delivery as well as for the new challenges they face after the birth of the child.
Both, mother and father should be counselled and educated during antenatal period to prepare them for the new challenges they may face.
Well trained support groups should be established and made readily accessible for parents.
Q. Your plans for the future?
A. My main aim is to educate the grassroots level, the community midwives and nursing staff with new development. We practise to identify high risk groups and get them early to institutions where facilities are available for care.
For this I am planning to visit the peripheries and conduct workshops for community and hospital staff with our expert resource personnel.
To minimize maternal deaths due to direct causes like, haemorrhage, hypertension and sepsis with dissemination of current evidence based practice among health care providers.
To improve the standards of neonatal care at the time of delivery and afterwards with modern available facilities. To train and upgrade the knowledge and skills of neonatal care staff in the neonatal intensive care units.
Q. Your message to physicians, carers and mothers.
A. The woman planning a pregnancy should plan it with pre conceptional counseling and get adequate and shared antenatal care. She should get emergency obstetric care without delay in emergency situations. Availability of standard neonatal care at the time of delivery for complicated pregnancies should be strengthened in all hospitals with maternity care services.
Mothers need to obtain basic knowledge about the pregnancy and the available facilities, before conceiving.
Planning the pregnancy should be done with advice after discussion with the family health midwife or the medical officer of the area.
If they have medical or other diseases they need to take advice from the relevant specialist prior to starting pregnancy. They should follow important health messages and participate in parentcraft classes. Mothers should be careful with their food and drinks, and the air they breathe as polluted water, food and air can cause diseases to the mother as well as the fetus intrauterine.
They are advised to avoid application of cosmetic skin creams, makeups, paints or dyes as the composition of these products are not clearly mentioned. Some of these items may contain heavy metals which harm the mother as well as the fetus.
It is important to space pregnancies to keep at least two years before conceiving the next pregnancy after childbirth. The father and the mother should get advice about the suitable family planning method during the antenatal period from family health midwife or the medical officer of health of the area.