Maternal Health in Africa

The New York Times has an article on the obstacles to safe childbirth in Tanzania.

I worked in two other African countries thirty years ago, and it doesn’t look like much has changed in these isolated and poor rural areas.

… Only 20 percent of women in the area give birth at the hospital, and many do so only when they need Caesareans. Many women say they simply cannot afford the hospital. More than 50 percent stay home to give birth, and the rest go to local clinics that cannot handle emergencies or perform Caesareans….

Our 120 bed hospital got electricity when I was there., and it was a big help. But before then, our hospitals used  a generator,  which is turned on in the evenings or for emergencies. Usually our midwives delivered  using a kerosene lantern. If you are lucky, you have an airconditioner or operate early in the morning when it’s still cool.

After I left, our nurses did the Cesarean sections, as described in the article. But we didn’t use ether. At one hospital, we had a nurse anesthetist or I gave spinal anesthesia. But at another hospital, we gave a Ketamine drip, controlled by the guy who usually cleaned the floors.

When I worked in Africa, just as described in the article, lots of women delivered at home with semi trained “birth attendants”, or at small midwife run clinics with limited resources.

The article says that patients had to supply a birthing kit; we were luckier:  we got funds from Europe, and our clinics were run either by churches or local authorities who helped fund supplies.
But in those days before HIV, friends in the US or Europe would wash up the latex gloves and send them on.

Our area had three clinics run by nurses, and all had access to cars for emergencies (usually a priest or a businessman). But in rainy season, the bridges might be under water or washed out, and even in the dry season it took an hour to drive to the clinics, all of which were less than twenty miles away.

Since our hospital had been there for years, the nuns were trusted, and since our tribe’s tradition was for moms to deliver with their own mothers, a lot of them would come with a relative to cook their own food (usually mom or little sister) and stay for free until they went into labor.

But some still delivered at home, with traditional midwives. Often the traditional midwives want to make labor faster, and give herbs. The result is sometimes a dead baby or a ruptured uterus. Depending on their experience, they might or might not recognize problems.

So when I worked in Liberia, before the civil war the government has programs to “certify” these midwives, who study for three to six months and learn hygiene, how to recognize common problems, and how to use simple medicines.

So how do you improve the safety of childbirth?

The obstacles are often not easily overcome.

You are often fighting the mother in law, or traditions. There is little or no money for things like hospitals, and sometimes the immans or local tribal shamans, and even some indigenous Christian churches forbid using the local hospital, which in rural areas is often run by a Christian church or may be run by another tribe.

If you live miles from the hospital, unless you stay there during your ninth month, you won’t make it in time for a delivery. And often women have other children to care for, and can’t afford the time off or the fee to stay there.

If you work in a town, or in the countries of southern Africa, you have more access to cash. Many of our women had relative working in the mines or cities of South Africa so they did have a small amount of “cash” to pay the fees. (We allowed the truly indigent to send a relative to work off the fee, which was the same price as the mother would give a traditional birth attendant).

Then there are the medical reasons for death in childbirth.

The African women have an oval pelvis, so that if the head “sticks” in the hole, the pressure on the tissue will cause it to rip, causing a hole where urine leaks continuously. The best and easiest treatment to prevent this is a Cesarean section, although forceps/suction delivery sometimes would be enough.

Sometimes mom would refuse a Cesarean section (local beliefs was that if mom require surgery, it meant she had committed adultery and was being punished). I know doctors who were forced to do the risky version and extraction, sometimes with a symphysiotomy (don’t ask) for these ladies…

The Times article is a good summary of some of the problems medical personnel face.

So how do you start to improve the safety of childbirth?

Money helps. Give to your local church, since many churches support mission hospitals and clinics that are in the most isolated areas. The UN is also a big help, as are many NGO’s.

Locals who are doctors or nurses often will stay in the area if they receive a good salary. Many help support and pay school fees for many relatives, so when I hear the clueless condemn the “brain drain” I get annoyed.

Another major obstacle is lack of ordinary infrastructure: roads, electricity, clean water, safety measures against criminals and stray animals such as baboons that can destroy a village’s crop. in one night.

Here in the Philippines, death in childbirth is rare in our area (although alas too common in poorer rural areas), because nearly every village has a midwife, and often the towns have ambulances and district hospitals. Yet even here, one of our neighboring farmers lost his wife from Toxemia, because she didn’t realize the need for prenatal care, and only went to the midwife when she “swelled up” and got sick.

As for “Family planning”, the favorite idol of the rich and famous, well, most African tribes have used traditional methods to space children for generations (prolonged breastfeeding, non vaginal intercourse, withdrawal, polygamy, and abstinence).

The real obstacle is the danger of death. If a mother knows that her children will survive, she will have fewer children, and carefully space them so that they can be cared for. If the mother knows that a measles epidemic will wipe out half her kids, she will have more kids. No kids, no one to care for you when you are old. It’s as simple as that.

Finally, when you read about Africa–or Asia for that matter–, you need to know that development is spotty.

You can find up to date cities, but down the road and off the main road it changes back to the past.

So read the Times article, and remember it the next time you hear or read someone who praises the good old days or points to people in the third world who live in simple huts and seem not to need all the “stuff” we do.

Then thank the Lord that you live in a country where death in childbirth is rare, and most kids live to grow up.

DDT is sometimes the best answer

The death rate was actually once lower, but then economic problems, and the banning of DDT caused a rebound of disease carrying mosquitoes, and a resurgence in these diseases.

But it’s not only malaria: Southeast Asia has had a rebound in Dengue fever in the last few years., and a recent upsurge in Latin America has infected over 100 thousand people this year so far.

Both diseases are carried by mosquitoes, but different mosquitoes. However, prevention for both types are about the same: get rid of standing water, spray ponds and standing water with insecticide, wear long sleeved clothing and use insect repellent, and use screens or mosquito nets to protect you at night.

Our province has dozens of diagnosed cases each year (and probably most cases never see a doctor). The headlines today are that eight kids in Cebu died from Dengue; presumably that means our mayor will find money to spray our open ditch sewers, and other standing ponds to get rid of the mosquitoes. (FYI: The larvae can grow in cans and tires in vacant lots, but not the muddy water of rice paddies).

The headlines all blame it on “global warming”, but when you know history, that Philadelphia had a yellow fever epidemic in 1790 (carried by the same mosquitoes as Dengue) you can see it’s the bugs that have to be kept under control or they’ll come back.

Thanks to BillGates and others, there has been a lot of money being invested in Asia and Africa to control disease, including malaria. That means controlling mosquitoes, from teaching people to drain fetid water to using mosquito nets with insecticide in them.

So I am upset when I read that some environmental scientists are striving to stop poorer countries from using DDT.
Luckily, they didn’t ban DDT this year, but “experts” are “worried” about side effects of DDT…

This article argues wait a minute: You should worry first about those 800 thousand African children who die from Malaria each year, and worry about a theoretical risk of cancer or infertility later.

Although the International Agency for Research on Cancer rates DDT as a possible human carcinogen (along with, notably, several pharmaceutical drugs), not one case-control study of DDT’s human carcinogenicity has been affirmatively replicated. Breast cancer furnishes the clearest example: the first study to correlate DDT exposure with statistically elevated risk17 has now failed to be replicated at least 8 times18-25, and of these later studies, some found exposure to significantly reduce risk24, 25. Much the same can be said of studies indicating involvement of DDT in multiple myeloma, hepatic cancer and non-Hodgkin lymphoma26, 27.

For poor countries, the choice may be to use cheap, fairly non toxic DDT (albeit with a small number of long term side effects since it is stored in fatty tissue).

Because the alternative is newer insecticide that can cause acute poisoning, have few long term studies, and are so expensive that many countries can’t afford them.

Yet the claims about infertility caught my eye.

That should be easy to check.

You see, 56 years ago, DDT was first used to fight an epidemic of typhus in Naples LINK

Yet no maternal problems were found there link.

Typhus is spread by lice, and lice are spread from person to person. It is notorious for killing people in times of war.

The traditional way of control was to isolate the patient, burn all the clothing, wash everyone in contact with the patient, and sterilize their living quarters.

Nowadays we have antibiotics to treat cases, but not in 1943,

To make things worse, it was winter, people couldn’t bathe due to lack of water, and often kept their clothing on to stay warm. People crowded into cellars and caves during air raids, many were malnourished, and the city’s water and sewer system had been largely destroyed by bombing. To make things worse, transportation was difficult, and no one was sure who was in charge.

Yet in January 1943, Naples proved that one could stop a typhus epidemic by tracing cases and their contacts, and by treating the entire population by spraying them and their clothing with DDT.

Remember, this was wartime, so people didn’t have spare clothes. And how can you spray 100 thousand people a day if you require them to get naked in public?

So they sprayed the outside of the clothing, they sprayed their hair and their hats, and then they put the sprays into the sleeves, neck and legs of the clothing and sprayed the skin.

Over 2 million people in Naples alone were sprayed at least once.

And within a month, the cases of typhus dropped dramatically. The epidemic was over.

No, you can’t get rid of mosquitoes that easily.

However, if DDT was such a problem for humans, then we should be able to prove it by doing more population studies on people in the Naples area.

And while you’re at it, ask them if stopping the epidemic was worth it.

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malpractice and the cost of medicine

At a recent meeting of the American College of Obstetricians and Gynecologists, a paper was presented that shows a strong correlation between the rate of Cesarean sections and the problem of lawsuits.

“States classified as having a medical liability crisis or crisis brewing by ACOG [the American College of Obstetricians and Gynecologists] have significantly higher rates of cesarean delivery, and this may reflect a pattern of defensive medicine in response to the liability climate,” said Elizabeth A. Platz, MD, from the Medical University of South Carolina in Charleston.

Well, how bad is the problem?

Total cesarean and primary cesarean rates are currently as high as 30% of total births in the United States, up from 4.5% in 1965. In 2003, 76% of all American obstetricians reported at least 1 litigation event, with a median award of $2.3 million for medical negligence in childbirth.

There are some things you should know to put this all into perspective.

One: when you do a delivery, within minutes you literally can go from a simple delivery to an emergency where you might lose the mother and/or the child. This is where skill makes the difference in life and death.

But sometimes, all the skill in the world won’t prevent a stillborn child.

If you have a baby with Cerebral palsy or brain damage, often parents assume that the damage was caused by the doctors not doing a Cesarean section fast enough.This assumption has been encouraged by lawyers who urge families to sue for “damages”.

So physicians often feel impelled to do a Cesarean section for any sign of a problem, even though a lot of times “watchful waiting” or other interventions work just as well.

You see, the outcome may not be different, but the parents will feel that the doc did everything to save the baby, and so are less likely to sue.

In contrast, a conservative approach takes time and energy.

One cannot overestimate the emotional stress to physicians by such lawsuits.
Never mind that most cases of cerebral palsy have little to do with lack of oxygen to the baby at time of birth (”fetal anoxia”) but are caused by a baby sick from intrauterine problems, often caused by smoking, high blood pressure, diabetes, medications, or most commonly viral infections.

Never mind that Cesarean sections have their own risks for both mom and baby.

To do a Cesarean section safely, you need an anesthesiologist, an operating room, and nurses right there. Most larger hospitals have these available, but even then it may take ten or fifteen minutes to get everything ready.

True, a lot of problems are prevented by doing a C-section when you see fetal distress on the monitor.

Sometimes, especially with very long labor and a child who may be too delicate to survive prolonged labor (the most common reason for Cesarean section is prolonged labor due to a large baby: often called dystocia).

This is especially true in first babies, where mom’s tissues have never been stretched by previous childbirth; and sometimes the baby is simply too large to deliver at all.

So, sometimes an emergency C-section will save a life.There are also times that you might see signs of “fetal distress” on monitors, and have to deliver as soon as possible but don’t necessarily need emergency surgery. Giving oxygen, placing mom on her side, relieving her pain, and a forceps delivery should be done.

But how many abnormal patterns on modern monitors are caused by mother’s distress-from the discomfort in sitting with cords attached, as opposed to walking around an changing positions during labor?

A lot of cerebral palsy is caused by problems before delivery: especially viral infections. So when you see the pattern of “fetal distress” on the monitor, it is because the kid is already sick, and surgical intervention to speed up a delivery doesn’t make any difference.

But one cannot underestimate the devestation of a mentally handicapped child to a family.

Fifty years ago, families had several children, so if you had a severely brain damaged child, you put it into an “institution” and went on with your life.

This practice has, thank God, been eliminated, for most of these children do better in a loving home.

But nowadays, often families face the difficulties of raising a child, with limited community support and problems getting their care paid for by their insurance.

So they sue.

Like the lawsuits over vaccines cause autism, there are reasons: the need for money for the child’s treatment being the main one.

But the guilt of the parents is another: because too many people blame themselves if their child is not perfect. This is not logical: No religion nowadays teaches that God punishes parent for sin by harming their child. But the superstition remains, and it is easier to find a “bad guy” for the problem…So how often does a Cesarean section need to be done?

Well, our rate in Africa was five percent, to save the mom’s life. But sometimes we lost kids who would have elsewhere been saved.

But in the US, one way to estimate what the rate would be without the lawsuit worry that pressures a physician to jump to do a C-section is to find the rate in a population that can’t sue.

There is one: The Indian Health Service, being federal, makes it very difficult to sue, unless you can prove negligence.

Several studies show that the rate of Cesarean sections is much lower: about 7% ,

The authors suggest:

The community’s low rate of cesarean delivery is primarily the result of a decreased use of cesarean delivery for labor dystocia and an almost universal acceptance of trial of labor after cesarean delivery. Cultural attitudes toward childbirth, design of the perinatal system, and genetic factors also may explain the low rate of cesarean delivery.

But that low rate is also rising.

The Native American population has some differences: many clinics have care by midwives, who are usually Native Americans.

The average number of children per woman is higher than the general population.

And many Native Americans have gynecoid (round) pelvises, which means they can easily deliver even a huge baby, and would be good candidates for “trial of labor” after having a Cesarean section in an earlier pregnancy.

Yet there are higher risks among Native Americans too: Many teen-aged pregnancies, some without prenatal care. Older moms with diabetes or high blood pressure. And on some reservations, a high rate of obesity.

So with all the dubious talk of lowering health care cost, one way to help is to mandate insurance for disabled children, limiting lawsuits to cases where negligence is obvious.

Take away the need for defensive medicine and you will end up with more efficient medical care.

Another way might be to take a public health approach to having a baby: using midwives who can spend more time with mom to educate her and to stay with her during labor.

But until physicians aren’t pressured to order expensive tests and procedures such as Cesarean sections, partly by fear of being sued for missing a rare problem, the cost of medical care will continue to be excessive.

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Nancy Reyes is a retired physician living in the Philippines. She worked for the IHS for ten years.

Swine Flu

One gets the impression from many news stories that the so called “Swine Flu” is going to wipe out humanity.

Calm down and take a deep breath.

One reason that “swine flu” has such an ominous echo is because the last time it threatened, back when Gerald Ford was president, it was believed that swine flu was the cause of the 1918 influenza outbreak, that killed 40 million people, more than all of World War I.

So the news stories are echoing that fear. Here in Asia, the airports have gotten their “thermal scanners” out of storage.  (These scanners were used to screen incoming passengers for fever, and used for the SARS epidemic)

However, since then, newer theories are that the 1918 epidemic was actually a variation of bird flu, that is, the influenza virus included particles from influenza that affects birds.

Bird flu right now is a ticking time bomb, with over 100 deaths, mainly in young people who have been in contact with poultry, in countries as far flung as Indonesia and Nigeria.

But influenza that is mixed with pig influenza is not “new”. It happens all the time.

There are two types of influenza: the ordinary type, that hits nearly every year, and then “pandemics”, such as Asian Flu (1957-58) (believed to have bird virus in the mixture) and Hong Kong Flu (1967-69) (believed to have pork virus in the mixture). Both of these started in Asia, presumably when animal influenza virus combined with human influenza virus and then spread. To make things more complicated, avian type influenza has been identified in pigs.

Why China? Probably because of back yard pigs and poultry on small farms. And of course, there are more such farms in China than elsewhere in the world, and better transportation for the germs to get out.

The present Swine Flu epidemic is believed to have started in a large pig farm in Mexico, although full epidemic studies are not available.

The early reports were that over 100 people died in Mexico. However, only seven of these deaths tested positive for Swine Flu. So the early news stories about the high mortality might not be true.

Indeed, some scientists are quoted in the LATimes as saying that this version is less dangerous than run-of-the-mill influenza, that kills a couple thousand Americans every year.

So essentially, what is going on is a second “influenza” season, with, of course, a lot of people sick at the same time and some even dying of influenza or bacterial pneumonia that they get on top of the influenza epidemic.

…(in) a typical flu season. In the U.S., between 5% and 20% of the population becomes ill and 36,000 people die — a mortality rate of between 0.24% and 0.96%.

The bad news is that it may take three months to get a vaccine to prevent the disease.

But common sense isolation (keep the kids away from Grandmom, avoid crowds, wash your hands a couple times a day, don’t go to work if you feel sick) also will help the virus from spreading.

And, of course, there are now anti viral medicines which, if started early, can decrease the seriousness of the illness.

The currently circulating swine-origin influenza A (H1N1) virus is sensitive to the neuraminidase inhibitor antiviral medications zanamivir and oseltamivir, but is resistant to the adamantane antiviral medications, amantadine and rimantadine.

So the bad news is that the world is probably going to have an influenza outbreak, but it won’t be the “big one” like 1918, but more likely a smaller pandemic such as 1957or 1968.

Chart from Wikipedia:

One more note on mortality.

The Spanish Influenza epidemic of 1918 followed World War I, and some of the excess mortality might have been from the widespread famine at that time.

Also, many of the deaths may have come from secondary bacterial infections: which remain a serious complication of influenza even nowadays.

So the good news is that the Swine Flu epidemic is not a major danger to the world, and there are treatments for those with it.

The bad news is that, like previous influenza pandemics, it may end up killing a million people, many of them young people.

Since the news changes from hour to hour, you need to check up on the headlines (my information may be “old” by the time you read this). And if you get sick, check your local news to see if influenza is in your area.

But this influenza pandemic, is not the “Big one”: waiting in the wings: Bird flu, which some experts think is only a matter of time until it too becomes epidemic.

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The CDC has a swine flu podcast LINK

Shingles pain"Back to using narcotics

No one knows why the virus decides to break out, but in some cases a lowering of immunity is suspected: often we see it in pregnant women, or in people who have various myelodysplastic syndromes (we used to call some of these “pre leukemia” but a lot of them go on for years and never get leukemia, so they changed the name).

But it is most common in the elderly.

Shingles is also called “Herpes Zoster” (not related to Herpes the sexually transmitted disease–there are dozens of Herpes viruses). Usually the disease is not “serious” (unless it involves the eye), but it is painful…or should I say PAINFUL. The Wikipedia page describes it as “..stinging, tingling, aching, numbing or throbbing, and can be interspersed with quick stabs of agonizing pain.”

The main treatment in the good old days for the acute pain of shingles was painkillers, usually with codeine, and high dose prednisone .

More recently, anti viral medicines are being used to shorten the course of illness, along with newer medicines such as gabapentin type medicines and anti depressants. Analgesic patches are used, but the high rate of allergy to these have made them less popular than we had hoped.

The acute stage of Shingles only lasts a few days or a few weeks, but despite the pain a lot of our older patients refuse to take pain medicine: some for fear of “addiction” and others because they grew up in a “Stiff upper lip” culture where pain medicine isn’t used.

The problem? Post Herpetic Neuralgia. The more pain you have in the “acute” phase, the higher the chance you will continue to have a painful, sensitive area after the rash disappears.

So how is best to treat the “acute” phase of shingles?

Well, a recent study comparing all these medicines showed that narcotics are best. The narcotic they used was Oxycodone.(in many medicines, including Oxycontin) Often patients with mild cases take Tylenol/acetaminophen/paracetamol or Ibuprofen/Advil/Motrin, but they don’t give sufficient pain relief.

“Oftentimes patients are told that the rash will heal in two or three weeks anyway, and the pain will go away, so they’re not given something for the pain unless it’s excruciating,” said Robert Dworkin, Ph.D., the University of Rochester Medical Center pain expert who led the study. “But moderate pain can stop people from working, or enjoying their hobbies, and it can also make some people depressed or anxious. So there’s good reason to treat all pain from the infection.”

Similarly, Gabapentin (which is very valuable in post herpetic neuralgia pain) has to be slowly increased to limit the sleepiness side effects, so you just can’t use a high enough dosage in the acute stage.

So if you get a case of shingles, go to your health care provider to get a course of anti viral medicine.

And don’t have a stiff upper lip: Take enough pain killer to feel comfortable, even if it means taking narcotics.

But the sedative and severe constipation side effects of narcotics limit their use in many older patients, especially constipation side effects when used for a longer period of time.

So if you are the small percentage (up to 30%) that do develop the Post Herpetic Neuralgia syndrome, your doctor will probably treat you with old fashioned tri cyclic antidepressants and Gabapentin or a similar seizure medicine. Both of these work for nerve pain, and are non addicting. Sometimes we just have to use narcotics for this type of pain too, but it’s more controversial: most of my patients thought the Gabapentin worked better, but sometimes needed a narcotic analgesic to supplement the other medicines, especially at night.

If you do not get enough pain relief to function normally, or if the medicines make you sleepy, ask for a referral to a pain specialist.

But in the acute phase, if you need narcotics, you probably should use them to prevent this complication.

Most people wait until they can’t stand the pain, and then end up taking a higher dose to get relief. Wrong. The trick is to figure out a dose that works but doesn’t make you sleepy or confused, and then figure out how long that dose lasts, and then take the next dose shortly before the pain would usually return. Pain specialists usually figure out the dosage for their chronic pain patients, and switch to long acting narcotics, but for acute shingles pain, usually we stick with the short acting medicines, which usually are a mixture of tylenol or advil with a weaker medicine like codiene or low dose oxycodone.

And now for the good news: Some studies suggest that if you give a shot of Chickenpox vaccine to older people, you see fewer cases of Shingles, and the cases you see are less severe, with fewer problems. Not a cure-all, but with the increase in the aging population, a vaccination that might become routine in the near future.