For decades, the hallmark of a health system’s success has been its measure of maternal outcomes; the ability to prevent mothers from dying of pregnancy-related complications.
What did this truly mean? That two key things were ignored: the quality of life of the mother who survived; and the outcome of itself - the baby.
We focused so much on dealing with reducing maternal mortality that to date, we have still not defined metrics for evaluating maternal morbidity. We cannot measure the burden of a medical condition if we have not agreed on how to define it in the first place.
Juliet* is one the jolliest people you will ever meet. She is a nurse at the paediatric unit, well loved by her little patients. I once jokingly told her that the children probably thought she was one of them because she had chubby round cheeks like them. We were walking out of the wards heading to the carpark at the end of the shift.
Juliet paused, smiled and casually stated that this was the impact of long-term steroid medication. I looked at her, puzzled. For the next hour, we forgot about getting home as Juliet took me through the horrors of her childbirth.
She was newly married and excited to be expecting their first child. When the ultrasound revealed that they were carrying twins, she and her husband were doubly excited. She giggled and exclaimed at just how naïve they both were regarding the chaos of raising two babies! Silly them, they thought it was all rhyming names, cute matching his-and-hers outfits and fabulous pictures for social media.
Being young at 28, and healthy, Juliet’s pregnancy was quite smooth, save for the excessive abdominal size that made her feel like a whale in the last few weeks. Her antenatal visits showed she was doing well, her blood pressure remained good throughout, and her efforts in taking the iron supplements had paid off, keeping anaemia at bay.
One morning at 38 weeks, Juliet woke up with a headache, which quickly turned into a pounding racket in her head. Her husband had left for work but her mother-in-law was staying with them. She drove her to the hospital for a quick checkup as her clinic was scheduled for the next day. Just as they pulled up outside the emergency department,
The emergency response was activated and Juliet was wheeled straight to the maternity unit. Her blood pressure was off the charts and the Eclampsia Response Protocol was set in motion. Within four hours, Juliet was in the operating room, convulsions and blood pressure having been brought under control by medications. The babies needed to be delivered immediately to give them a fighting chance; and to allow mum’s body to heal.
Juliet regained consciousness four days later at the intensive care unit (ICU). Both her traumatised mother-in-law and a very distraught mum, who had travelled to be with her, were camped at the bedside, whispering non-stop prayers. She asked about her babies even before asking where she was.
Juliet’s recovery was excruciatingly slow. Despite everything else settling, her poor kidneys, which had suffered acute failure, were taking their time to recover. She remained on dialysis even as she learnt to breastfeed her babies, attempting to catch up on the time she had lost.
Nine months later, Juliet was officially declared to have chronic kidney failure and pretty much sentenced to a lifetime of dialysis unless she got a kidney transplant. She told me that she was bound to her employer for her entire employment duration due to the kindness she had been shown. The hospital she worked for had footed her kidney transplant costs and continued to pay for the very expensive post-transplant medication she now has to live on.
She was happy to stay, caring for the little ones in the wards whole-heartedly because she knew what it meant to need care and receive it with love. She is grateful for her double blessings, a healthy and mischievous 14-year-old duo, Samantha and Samuel.
Juliet represents a population of women whose story is quickly forgotten once they are discharged from the maternity unit alive and transitioned into other specialty care.
On the flip side of the coin, we are finally coming alive to the fact that the reason the under-five childhood mortality rate in Kenya is stuck at 41 deaths per 1,000 live births is because we are unable to tame the neonatal (babies less than 28 days of life) deaths that contribute to 21 of these 41!
But even as the clarion call is sounded across the globe to reduce preventable newborn deaths under the EWENE banner (Every Woman, Every Newborn, Everywhere), Dr Christine Manyasi, one of the most passionate neonatologists I know, aptly reminds us that it is not enough that the babies live; the quality of life we bestow upon them is even more important.
Dr Christine, a fairly soft-spoken, mostly introverted person, literally metamorphosises into a firm and outspoken advocate where newborns are involved. She does not sugarcoat anything and will very boldly call us all to order when we fail the baby at a personal, institutional or systems level.
Her mantra is consistently solid: the maternity team must do everything to ensure the baby is born in the best possible condition; the receiving newborn team must be competent enough to ensure the babies breathe, recognise complications early and institute appropriate care in a timely manner, or refer appropriately; and the health systems
This calls for proper management of labour, skilled workforce for effective newborn resuscitation, and availability of proper newborn units and newborn ICUs with basic lifesaving medication such as caffeine citrate and surfactant. These are interventions that are not out of reach; yet their impact is immense.
These are interventions that will markedly reduce lifelong complications such as cerebral palsy, seizures, developmental delays, pulmonary hypertension and heart complications.
No mother starts the pregnancy journey envisioning the possibility of a baby who has to live with cerebral palsy. It is grossly unfair for us to fail her to such an extent as to sentence a family to lifelong special care provision when we have the capacity to avert such outcomes.
As we measure maternal and newborn mortality, let us add the measures of morbidity that those who escape death have to live with. We are cheating when we calculate the cost of poor maternal care, and fail to acknowledge those who may have cheated death, but their survival may be an even worse life sentence.
The story is not complete, until both the ship and the cargo not only dock safely, but also in good condition!
