A Long and Dangerous Journey

Complex as it is, pregnancy is made more difficult by conditions and complications that put both mother and fetus at risk

By Jin Paul De Guzman

"I am going to the sea to fetch a new baby, but the journey is long and dangerous and I may not return."

    -Tanzanian saying, quoted in the 2000 Report of the United Nations Population Fund

Although much has changed, the days when a mother has to die just to give birth are not completely gone.

    United Nations data show that as late as 1995, one out of every 75 Filipino mothers have the risk of dying at childbirth-whether it be their first time to get pregnant, or second, or tenth. The 2000 State of Population Report prepared by the Commission on Population showed that practically ten women die at childbirth every day. The causes of these deaths are largely preventable; 1996 data from virtual-asia.com show that two-fifths of these deaths-translating to about 1,500 annually-happen at normal delivery.

    The dangers of childbirth, obviously, also hover over the infants themselves. Although between 1993 and 1998 infant mortality went down from 26.2 deaths per 1,000 live births to 19.7 deaths, the progress is much too slow.

    To understand the full extent of this problem requires the examination of other issues-from socioeconomic to moral to environmental aspects, from global to national to individual levels. Wherever one looks, the danger of pregnancy is rife with linkages.

    Which, to exaggerate the point a bit, adds a blackly humorous dimension to the cliché "the miracle of life"-that life persists at all, despite these obstacles, is indeed a miracle.

    Doctors and other health professionals have always stressed the importance of preventing health problems from arising-it is the safest, surest, and most inexpensive way of ensuring health and well-being. In pregnancy, the need to be careful doubles, even trebles if the ones inside the womb are twins. That is why the importance of prenatal checkups can never be stressed enough.

    Dr. Esmeraldo Ilem, training officer of the obstetrics and gynecology department of the Jose Fabella Memorial Hospital, says: "For normal pregnant patients, we follow a schedule-during the early stage of the pregnancy, checkups should be done monthly. In the eighth month it becomes every two weeks; in the ninth month, prior to birth, the patient has to be seen weekly."

    If the pregnancy is deemed problematic, or high-risk, checkups should be done more frequently and more extensively. Explains Dr. Ruth Gutierrez, head of the obstetrics and gynecology department of the University of Santo Tomas Hospital and president of the Perinatal Association of the Philippines: "[If you're going to think about it], all complications that could happen during pregnancy are completely preventable only if pregnant women come to us early enough." Dr. Virgilio Castro, head of the UST high-risk unit, agrees: "[If they come to us and then are managed properly], there should be no reason for complications."

Risk Rundown

    Although a large number of factors could make a pregnancy high-risk, from abnormalities in the pregnancy to several antepartum factors, and commonly these conditions are interrelated, the focus of this story shall be on the most common diseases that could complicate a pregnancy.

    The most common of the medical conditions that can cause some degree of complications are toxic diffuse goiter and iron deficiency anemia, to a lesser extent gestational diabetes mellitus, and most significantly, gestational hypertension.

    Toxic diffuse goiter or Graves's disease could cause some serious complications during pregnancy-the abnormal release of thyroid hormone has significant impact on both mother and child. Often, the antibodies causing the abnormal release of thyroid hormones penetrate the placenta, speeding up the fetus' heart rate and slowing down its growth.

    Meanwhile, the prevalence of anemias, specifically iron-deficiency anemia, among pregnant women isn't any less serious. In the 1998 National Nutrition Survey it came out that half of all pregnant Filipino women are plagued by IDA. Needless to say, what afflicts the mother transfers to the child. Six out of every ten newborns suffer from this condition.

    In diabetic pregnancies, the most number of neonatal deaths results from congenital malformations. Especially among Type 2 diabetics, the use of oral hypoglycemics, particularly in the first trimester, has been reported to contribute to cardiac defects, ear malformations, and the VATER (vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, and radial and renal anomalies) complex (Merck 1992). For the mother, diabetes raises the risk of developing infections and having early labor. It also strongly relates to hypertension.

    Nondiabetic women must be screened for gestational diabetes, which affects both mother and child, but usually resolves when the child is born. For gestational diabetics, adhering to a strict diet, performing mild exercises, and checking plasma glucose levels regularly are a must.

    Gestational hypertension or pregnancy-induced hypertension is tagged as the most killing of these conditions. In a virtual-asia.com posting, "hypertension complicating pregnancy, childbirth, and puerperium" is the reason behind nearly a quarter (23.6 percent) of maternal deaths in the Philippines every year. Why it develops at pregnancy is not fully known, but Dr. Ilem cites four theories: "One is the woman's hypersensitivity to her pregnancy. For example, if it is the first time the pregnant patient is exposed to the placenta, there could be a hypersensitivity reaction. Second is [familial] reason-it runs in the family, and the pregnant patient could inherit it. Third, there could be underlying cardiac, renal, and other conditions, [which exist] independent of, but is worsened by, the pregnancy. Fourth is any condition that could give rise to a greater volume of the placenta. If the baby is very big, it will follow that the placenta is big, so the reaction will be great also. Or in a twin pregnancy when the placenta is bulky."

The Compliance Conundrum

    Unfortunately, even if a doctor stresses the necessity of prenatal checkups no end, patient compliance remains poor. Says Dr. Castro: "Before some patients come to you for consult they must be very serious already, and about to deliver." Adds Dr. Ilem: "Binibigyan namin sila ng prescription, only to find out hindi nila nabili, nakabili man hindi sapat, like if you say they have to take the medication for a month, maiinom lang nila for one week. Sasabihan na they have to follow up, hindi darating."

    Which is, to say the least, dismaying. Noncompliance has strong links to socioeconomic causes, but the risks grow geometrically by letting the need for medical attention pass. In this case, ignorance is most emphatically not bliss. Says Dr. Gutierrez: "Patients should know that there are such things as high-risk cases, and there are hospitals that have high-risk units. Like in USTH, we have the proper personnel to attend to them. Hindi basta obstetrician lang-these are people who have special training and whose primary aim is [the detection and management of high-risk cases]."

    To illustrate a point, Dr. Ilem says a considerable number of pregnant women are hypertensive, but have minimal to no prenatal checkups. "Alam na nilang hypertensive sila, hindi pa rin nagpapa-checkup, only to be seen with a more severe complication." Dr. Castro adds: "In pregnancy-induced hypertension, some of the complications-like abruptio placentae-could be reverted if not prevented, if only the patients have proper prenatal checkups."

Attendants Are Absent

    One major problem that continues to plague pregnancies in the country, whether they be "safe" or high-risk, is the fact that only a little more than half-56.4 percent-of all births are attended to by a skilled professional. Several reasons have been singled out, first of which is the uneven distribution of medical professionals. Sometimes the available birth attendant-as exemplified by the hilot-have limited training.

    In addition, most babies are delivered in the home, under the care of the aforementioned hilot, as well as paramedics like midwives and nurses. Only 31 percent of deliveries are taken charge of by medical institutions. This is not a liability: midwives for instance are completely capable in assisting births. Dr. Ilem says that in most developed countries, particularly the US, normal births are done under the care of midwives and general practitioners. Only in cases considered high-risk do the obstetricians begin taking charge.

    Fortunately the country is starting to handle births the same way. Aside from reforms coming from among the midwives themselves-most notable of which is the implementation of a more intensive four-year curriculum at the Integrated Midwives Association of the Philippines School in Iloilo-the medical community has also intensified its move to consider other health professionals as their partners in the delivery of health care.

    For instance, Dr. Ilem says the Fabella Hospital has strengthened its ties with health and lying-in centers. Under the initiative of the national government and the city government of Manila, he says that lying-in centers are built, and more people are being trained to attend to maternal needs. He adds that public education projects have been carried out "so people will know that these centers are built for them, so that they will develop the faith in these centers na hindi sila pababayaan."

    The UST Hospital also involves other health professionals in ensuring safe and healthy deliveries. Because it is also a training hospital, it regularly comes up with lectures, workshops, and postgraduate courses that not only involves doctors, but midwives and nurses as well. In February, for example, the obstetrics and gynecology department held a fetal monitoring workshop. Relates Dr. Gutierrez: "We taught them how to read the tracings of the electronic monitor, and at the same time we made them aware that there is such a thing as a high-risk unit, na kapag mayroon silang na-identify na pasyente we welcome them."

    And aside from continuing to improve the services of the unit-they are preparing to acquire a state-of-the-art 3D-4D ultrasonographic machine in a few month's time, and have started laying the groundwork to turn the high-risk unit into a Fetal-Maternal Diagnostic Center-it has also established linkages with the community. It has a tie-up with the Maria Clara Lying-in Center in Manila.

    Meanwhile, the Perinatal Association of the Philippines has also seen the importance of evenly disseminating knowledge and expertise to the different corners of the country. The PAP, says Dr. Castro, is "taking a bold step" in making the knowledge, skills, and technology reach the regions, so there will be "satellite perinatal centers throughout the country."

    These changes, the three doctors hope, will have a bearing on the general status of maternal and infant health in the country-aggressively take care of problematic cases, reduce and possibly eliminate the incidence of maternal and infant morbidity and mortality, and in the whole make the journey of pregnancy less dangerous.