Mother of all perils The health outlook of mothers, whether they've given birth to two or 12, and their offspring ultimately depends on the soundness of the society's health and economic support system
By Grace Roxas, Contributing Writer
In obstetrics, gran multipara or the state of having more than five pregnancies was a major red flag in gauging an expectant mother's risk profile and the corresponding need for health-facility-based delivery. That is until newer research evidence led health policymakers to say that all bets are off in terms of risk assessment by brood size. A study among African mothers in the early 1990s found that some gran multiparous cases never developed complications while there were mothers with only one to three kids who did encounter complicated childbirth. By 1997, the World Health Organization was calling for a shift from the gran multipara risk threshold, especially in developing countries where many women still gave birth in homes. "The modern view is that 15 percent of all pregnancies develop life-threatening complications whether the mother is rich or poor, healthy or not healthy, and whether the child is first born or not. And you don't know which ones will have risk until during the delivery process," says Dr. Junice Melgar, executive director of Likhaan (Linangan ng Kababa-ihan), a nongovernment organization focused on women's reproductive health. Modern risks having nothing to do with number of previous pregnancies and other traditional risk factors like age (i.e. too young or too old) and interval between pregnancies are partly responsible. Ironically, some of these might even be downsides of better modern living conditions, such as easier access to fetal nutrition. "They used to romanticize that pregnancy is the apex of womanhood, but not in this day and age. The healthier the babies are, the bigger their heads are, and so we're seeing more cases of fetal obstruction in recent years," Melgar observes. Such complications are not an automatic death sentence so long as the woman has access to skilled obstetric intervention as well as to certain procedures like a caesarian operation and blood transfusion. That's why the real correlation, adds Melgar, is between risky pregnancies and a woman's access to appropriate health services, whether by virtue of her economic status or the strength of the health support system.
Outside of complications and despite the scrapping of the gran multipara red flag, the tough toll of multiple pregnancies on the health of a woman and her offspring cannot be gainsaid. Melgar cites a cumulative risk calculation where every new pregnancy ups the risk ratio for the mother. This means that a first-time mother who has a 1:100 risk for example, will have a 2:100 risk ratio if she becomes pregnant a second time, and so on. "Every pregnancy depletes a woman since all the raw material of the fetus, like the blood and calcium, comes from the mother.... And very rarely can her health bounce back after pregnancy, especially if she is poor," she explains. In the Philippines, national health and nutrition surveys have shown anemia to be one of the toughest deficiencies to overcome, notably among pregnant women who have a higher required daily intake of iron particularly during the first trimester. Even a two-year gap in pregnancy might not be enough for a mother to recover. It might even worsen her condition if she was anemic the previous time around. Calcium also needs to be taken in high quantities. A deficiency results in a form of calcium cannibalism of the mother by the growing child inside her, resulting in possibly irreversible effects later on. Women predisposed to certain risks like cardiac problems acquire an added strain toward end-organ damage with each new pregnancy. Their circumstance might even move them to risky options like considering abortion, which is illegal in the Philippines and is therefore done underground by mostly untrained people. Melgar cites results of their local abortion studies showing that-contrary to popular belief that more teenage mothers turn to this desperate option-abortion is mainly resorted to by women in their late 20s and early 30s who have three to four kids already. At least one recent international study reinforced the hard effects of frequent childbirth and raising kids on the health of both mothers and children, especially those born late in a big brood. Researchers from Austria's Konrad Lorenz Institute for Ethology found that among 21,000 19th century couples in Utah, United States, with an average of nine children, the women's survival rates went down as their brood increased. This is said to be linked to the small intervals between births that separate studies have correlated to higher morbidity and mortality risks. Among their kids, the youngest were found to have had the least chance of getting past 18 years, a fact more pronounced in families of more than 12 children. "Evidence says the health of women during pregnancy is critical to the wellness of the newborn," Melgar points out. "In fact, [many of those who die] during the first 28 days are those with unhealthy mothers or whose mothers died." At around age five, the child is more plugged in to the living environment outside the mother's protective control. This is where the realities, kind or otherwise, of his living condition truly set in, as he has to get his equal share or fend for himself, as the case may be, just like everyone else in the family. Melgar sums: "For the woman to live, the health system has to be sound. For the child to live, the economic system has to be working well."
Pregnancy complications might know no social distinctions. But in a setting like the Philippines, where maternal deaths are high even by developing-country standards (162 per 100,000 live births) due to slow improvements in government health-care provisions, it's the poor who take the brunt. "Every pregnancy is a burden on the poor even without the element of population explosion because it puts a woman at risk, especially poor women who cannot avail themselves of emergency care when they need it," Melgar says. Three of four poor Filipino women still give birth in their homes assisted by the traditional birth attendant or hilot who usually tends to gloss over the risks involved. When things go wrong, that's the time the women go to hospitals, usually the overcrowded government facilities, in a nearly moribund state. Compare this with Indonesia, which used to have a higher maternal mortality, and now has a higher percentage improvement as more Indonesian women deliver under the care of skilled medical personnel. A crucial negative impetus to the local situation is the fact that half of all pregnancies here are unintended or unwanted. We may have come a long way from a time when having nine to 12 kids is normal, but Melgar says the decline from the present norm of six kids is not happening fast enough. Many Pinays, especially the poor, still have three to six children more than they want. Likhaan's newly minted qualitative study on the effects of the Manila city government's no-family-planning policy came up with some telling anecdotes in this regard. "The strain on relationships and the women's mental health is incalculable. They can't sleep. They're always anxious that they're pregnant. And the husband's tendency is to quarrel because the woman doesn't want to have sex just there and then. Gusto nila ng protection. So the man becomes suspicious and in two to three cases, umuuwi sa bugbog at hiwalayan," Melgar discloses. When she does get pregnant, how the woman handles her condition also matters. Other studies have looked into the tendency of women not to take good care of themselves during unintended pregnancies by missing prenatal checkups and not planning for delivery. Among kids, the Likhaan study notes inevitable undernourishment and anemia results as families have to share two pandesals for breakfast, eat instant noodles, or sometimes skip meals altogether. The children have to either stop schooling or to alternate attendance every school year. Melgar fears that with the withdrawal by the United States Agency for International Development of its support for artificial family planning next year in response to the government's lackadaisical policy, such dire scenarios might become more common as the rates of unintended pregnancies and complicated cases suddenly balloon. "We might be looking at a brewing reproductive crisis next year," she warns. M |
