A ball of dilemmas for pregnant women

By Dann Okoth

The young woman walked into the clinic, her face radiating the excitement of many a new mother. She was up for a routine early-pregnancy check-up, and when the nurse told her she was next in line, she called her husband and told him she would be out in 20 minutes. After all it was just a routine visit, and the pregnancy magazines had said this was one of the procedural trips she would have to make for seven months.

But it was not to be. The doctor said she had an irregular heartbeat and recommended further tests, which revealed a severe congenital heart disease.

"I told her the condition was not compatible with pregnancy and she had to terminate it to save her own life," recalls Dr Joachim Osur, a reproductive health specialist.

"I explained that her heart’s condition could not sustain the pressure that comes with a pregnancy and that it could kill her if she carried it to term," he added.

Stark choices

Torn between having to get rid of the pregnancy or carrying it to term and risking her own life, the young woman pondered the stark choices. She was a devout Christian and told the doctor her options were limited to keeping the pregnancy.

"She returned after a few days and said she had discussed with her husband and prayed about it and that everything would be alright," Osur recalls.

Weeks later things took a nasty turn for the couple. What they thought would be routine monthly visits soon turned into a daily nightmare, with the woman struggling to keep the save her life and the foetus. Four months into the pregnancy, she was wheeled into hospital in a coma—and died shortly after.

Medical experts say this case is not unique. Every year thousands of women with difficult pregnancies face the dilemma of having to terminate their pregnancies to save their own lives or give birth to severely deformed children.

The 2008-09 Kenya Demographic and Health Survey says there are about 488 maternal deaths per 100,000 live births, up from 414 in 2003.

Medical intervention

Most of these deaths are related to complications of unsafe abortion, difficult pregnancies and complications during and after delivery. Medical experts say though some of the conditions are fatal, they can be managed with prudent and timely medical intervention. "I had a patient in 2006 who had to make this very difficult choice when she was diagnosed with severe hypertension during her first trimester," says Dr Samuel Buguri, an obstetric gynaecologist in Nairobi.

Experts say the effects of high blood pressure range from mild to severe. High blood pressure can cause injury to the mother’s internal organs like kidneys, result in low birth weight and early delivery. In extreme cases, the mother develops preeclampsia – a condition characterised by high blood pressure and protein in urine. Swelling, sudden weight gain, headaches and changes in vision are important symptoms, although some women show few symptoms, according to the charity Preeclampsia Foundation.

Buguri says after three years of treatment, care and dieting, the woman conceived and successfully carried the pregnancy to term. "If you are thinking about having a baby and you have high blood pressure, talk first to your doctor or nurse," he says.

Yet it is not just the medical dilemmas that the women have to contend with; geographic, socio-cultural, economic, legal and regulatory barriers also impede access to reproductive health services, putting their lives at risk.

Take the case of Aisha, who was diagnosed with an ectopic pregnancy in September last year. Ectopic pregnancy occurs when the foetus forms outside the uterus, often in the fallopian tubes, resulting in a surgical emergency.

"This is because if left to grow the foetus will rapture the fallopian tube leading to internal haemorrhaging that could kill the woman," says Osur.

But despite the risks, the woman insisted she had to consult her husband before making a decision. He turned up the following day to announce that they would not terminate the pregnancy.

Severely deformed

"I never heard from them again," he adds, but the result must have been fatal.

The choice of whether to terminate a pregnancy or not has been contentious, presenting women with religious and medical dilemmas. And it is not just the life of the woman that is involved; often women have to make a choice between terminating a pregnancy and giving birth to a child that is severely deformed and will require life support.

Buguri cites the case of a woman he attended to suffering from spina bifida and advised her to terminate the pregnancy because she was likely to end up with a severely deformed child. The woman declined, citing religious beliefs.

Spina bifida is a birth defect caused by the incomplete closure of the embryonic neural tube. "Some children have fluid in the brain, a condition known as hydrocephalus and have to have a shunt inserted in the spinal chord," says Buguri. He estimates it would cost about Sh100,000 monthly to support such a child.

Experts pin dilemmas facing women with difficult pregnancies on three main issues: the desire to have a baby, the competition between science and religion and cultural issues. According to Joseph Karanja, an Associate Professor of Obstetrics and Gynaecology at the University of Nairobi, specialists, guided by guidelines from the Medical Practitioners and Dentists Boards, would help women access the best medical services.