Giving Birth in The Gambia

So, I haven't actually been to The Gambia. I just enjoy saying it because it is one of the few countries that gets a The. Not even La France gets a The, even though they call themselves "The France".

Anyway, I finally went to my first appointment with my "earth mother" (jordmor) here in Denmark. This is the woman who is assigned to deliver our baby; the American/British equivalent is a midwife. Nobody here is assigned a doctor for delivery - unless for some reason you are pegged as having a high risk pregnancy. My first appointment was supposed to be around week 13, but because things are so backed up here, I had to wait until just before week 19.

I don't know what I was expecting - but I was expecting something. But she (actually there were two of them there) just talked to me. "Wow - that's great you run so much! You saved me time convincing you to exercise. You should take more iron. Here are some brochures about breastfeeding. Here's the number to call when you go in labor." They didn't weigh me, take my blood pressure, measure me. And then they were like - "well, since you're just two weeks away from the next appointment with us, we'll just skip that one and you can come back in week 29. See ya in the third trimester! Good luck! Keep running!"

I admit, I did get to listen to the fetal heart sound for the first time. Sure that was nice, but I knew it would have a heart beat since I feel it kick nearly hourly.

So I started thinking... is it actually dangerous to give birth in Denmark? I mean how they heck do the ever get the impression something is wrong?

And that's when I started thinking about giving birth in places like The Gambia. I did a bit of research and found their infant mortality rate is around the 31st highest in the world. Angola actually has the highest at almost 20%! So is Denmark even close to this? Of course not. Denmark's infant mortality rate is .46%, the 12th lowest in the world and is, not surprisingly, lower than that in the US (.63%). But this number isn't really that interesting when talking about giving birth. Infant mortality rate includes all deaths in the first year of life. Most infant deaths that occur in the third world are sometime later in that first year due to infection.

So what about actual birth outcomes? Everyone reading this knows that mothers and babies alike are much less likely to die at birth in the developed world than in the third world. But why is this? And what if I told you that in the 1940's the perinatal and maternal mortality in the US were similar to what they are in the 3rd world now (between 3 and 4%)? What is it then that has made the difference and what should all mothers worldwide have available when giving birth?

Unfortunately the answer is not at all simple. So much changed between the 40's and the 60's. Well, actually, the improvement is not that complicated when it comes to maternal death; that rate fell drastically after the introduction of penicillin in the 50's. But what about perinatal mortality? In developing countries, most perinatal mortality occurs due to the baby in some way getting stuck, the umbilical cord getting compressed and the baby asphyxiating before it can come out. A myriad of things came together at once in the 50's and 60's ensuring that this basically never happens in the developed world anymore: fetal heart rate monitors and people who know how to read them, quick access to a person skilled with forceps or a cesarean section with anesthesiologists and obstetricians. APGAR scores give an idea of how the baby is doing seconds after birth and neonatal intensivists are on hand to take over if the baby was not doing well. And prenatal ultrasounds give warning when there may be a problem in utero. This, along with many, many other little interventions, is the modern "obstetrical package". And it consists of so many elements that have never been analyzed separately, so it is tough to say what really made the difference. Today almost all perinatal mortality occurs due to premature birth, and with access to a neonatal intensive care unit, it is only the very, very premature that don't survive. And, in all honesty, when born before 25 weeks, most will lead a life fraught with disabilities and health problems (there are exceptions).

So, thankfully, I have access to all of these modern interventins here and that is why Denmark does just as well as The US (I should also mention that there are two sets of ultrasounds here - my second is next week) and for much less money.

But, when my earth mothers asked if I wanted to give birth at home, I said no, no, no. And why, if my water breaks before 33 weeks, I'm going to have SR drive me to Copenhagen - or I'll drive myself. I have to be near a good NICU.

Normally I am not one for much medical intervention. But I have worked in the 3rd world delivering babies - and have seen how frequently things can go wrong. I was involved in a case where the umbilical cord came out before the baby- the family doc there gave me a warm saline bottle to hold the cord in, so the cord wouldn't spasm in cold air and cut off the blood supply. I sat there for almost an hour in the middle of the night, with my hands between this woman's legs. She only spoke Tz'utujil , and well, a little Spanish, so we were able to very little small talk. The Fam Med doc, who normally would have had my help, set up for a c- section. Finally another family doc arrived to set up the anesthesia. We performed a c-section, the baby was delivered, and the mother could not stop hugging me. But an hour later, the baby started not breathing properly and not reacting right. I apologized to her, but I will never know if she understood. They were driven to Guatemala City and the baby died on the way.

This is not a reality people reading this blog deal with and if they ever did, they would sue. When the blood supply of a baby is compromised time is brain cells and very, very unfortunately nothing happened quickly that night.

It's probably good for me to put things in perspective - and admit that most of the things I talk about on this blog (exercise, weight gain, etc) are not factors that make a big difference in birth outcome.

The modern "obstetrical package" is one of the few examples in medicine of an group of interventions that has saved a huge amount of lives. But, the other side of this coin is that deliveries in the US (and Europe) have become over-medicalized. Women's labors are started if they go slightly past their due date. If labor is too slow or there is even a blip of heart-rate deceleration on the heart rate monitor, women are rushed to the OR for a c-section. Not based on evidence, but simply on the idea that one must "do everything" and "not take chances". I'm not criticizing; it is tough to make decisions when it's no longer ethical to due a study about not using one of the interventions.

To end this post on a running note, this is perhaps one of the biggest benefits of running while pregnant: much lower chance of emergency c-section. Babies heart rates don't decelerate - they are strong due to all of that blood flow variation they have gotten through their exercising mom. So doctors worry less. Also, babies of running moms are much less likely to be large for gestational age and, to some extent, they are less likely to go beyond their due date. Run for your own health - and run to avoid the risks of the overmedicalization of labor and delivery! But the real risk of problems at birth is dependent on where you live - not what you do.

I have to thank The WHO, The CIA, James Clapp and Atul Gawande for their writings and reports, which I used in this blog post.

And finally, since SR is in Portugal this weekend, I have turned to dreaming about singing a pop duet with Enrique Iglesias. My two running songs of the day were "Escape" and "Heartbeat" by Enrique Iglesias. The only downside is his lyrics are uninteresting. But they worked well on my long run- on the first warm day of the year in Denmark!