Posted by Shefali Oza, as told to her by Dr. Jhapat Bahadur Thapa, MBBS
We recently had a 35-year old female come to our clinic for an antenatal clinic visit. She was pregnant with her seventh child. Of the previous six, only the first had survived. Four others were stillborn and one died on the third day of life. Such loss should be an inconceivable exception, yet is far from unusual in this area where maternal and child mortality is among the highest recorded in Asia.
When we tested the patient’s blood, we found that she was B negative (blood type: B, Rh: negative). This meant there was a risk of Rh incompatibility, which can arise if the mother is Rh negative and the father is Rh positive. Rh incompatibility, a condition that is easily prevented with proper medication, can lead to miscarriage or death of the newborn. When we tested the father’s blood, we found that he was indeed Rh positive. We conducted a preliminary ultrasound scan and the results were normal. Our staff counseled the couple of the probable Rh incompatibility diagnosis and the high likelihood that the baby may not survive. We recommended that they go to a health center better equipped to handle such cases, since our hospital expansion is still being initiated.
In wealthier countries, Rh incompatibility is rarely a problem because a medication called RhoGAM is given to the woman 28 weeks into pregnancy and again immediately after birth. This will both keep the fetus safe and remove the risk of Rh incompatibility for the next pregnancy. Unfortunately, in poor areas like Achham, RhoGAM is rarely an option. Since our clinic does not have RhoGAM, our pharmacist immediately called Dhangadhi, the capital of a nearby district. They told us that there was no RhoGAM in the entire city.
Two weeks later, at 5 AM on a Tuesday, the patient returned for delivery. Gauri, one of our auxillary nurse midwives, evaluated her and called me to come to the Nyaya Health clinic. Upon arrival, I found the patient had a breech presentation, meaning that the fetus was positioned to come out feet first. A quick ultrasound scan showed that the breech was the only abnormality. At 7:30 AM, I performed an assisted breech delivery and delivered a 3.5 kg female baby. We tested the cord blood and found the baby to be O positive and that she was not anemic, though close.
We ordered RhoGAM from a pharmacy where it is available and it arrived at our clinic at 6 AM on Wednesday, so we could inject the mother within 72 hours. Thus, in case of further pregnancy, the mother will be protected from Rh incompatibility. In this case, our patient would likely have lost her newborn daughter if she had not arrived at the Nyaya Health clinic for a skilled delivery.
This story highlights several important features of our work in Achham. The maternal and neonatal (death within the first month of life) mortality rates here are astounding, as are the number of stillbirths. Attenuating the factors that negatively affect pregnancy and delivery is critical for reducing these rates, particularly for mothers and neonates. While many complex realities influence pregnancies, the presence of a skilled birth attendant at birth is known to greatly reduce the likelihood of maternal and neonatal death, as well as stillbirths. Yet, a remarkable number of deliveries in Achham and similar settings continue to occur without these skilled birth attendants. As we expand our Community Health Worker program, a key goal is to monitor pregnancies through the district and provide safe deliveries. This is necessary since the difficult terrain and large distances can make travel to the clinic, especially for women in late pregnancy.
Since high-risk pregnancies can often result in emergency problems during delivery, our need for a hospital with surgical capacity is also clear. Our hospital will have rooms for such women to stay overnight so they are not forced to choose between difficult travel at the time of delivery and an unsafe delivery. Without our hospital expansion, for which we have initiated a capital campaign, we will continue to lose mothers and babies to tragic, and often preventable, circumstances.