Once a month, clinicians from Pediatrics and Maternity come together to discuss both specific cases and general coordinated care between the two wards. Maternal and child health are intricately linked, and the more communication and collaboration that occurs between these two departments, the better the outcomes for both mother and child. Tanya, Sarah and I were able to attend this monthly maternal mortality meeting, and one of the central discussions involved making the decision whether or not to induce labor in high risk pregnancies.
Worldwide, rates of cesarean section births usually hover around 15%. However, at Queens, 29% of births were performed by C-section in 2014. This unusually high rate of C-section births points to two major concerns that guided the discussion – first, why are so many C-sections necessary at Queens, and second, how does this influx impact long-term maternal and child outcomes here?
On any given day, the delivery suite at Queens ebbs and flows between the calm of just two or three mothers in labor to the chaos of sixteen or seventeen (more than half of whom are likely high-risk deliveries). Especially for pre-eclamptics or younger mothers whose hips have not developed fully, C-sections offer immediate intervention when fetal distress puts both mother and baby at risk. Queens sees incredibly high numbers of these types of cases, and one theory that came up during the meeting was the fact that prenatal care in district health clinics rarely provides adequate preventative monitoring for mothers due to both personnel and equipment constraints. Oftentimes, expectant mothers don’t seek prenatal care due to the time it takes to travel to the clinic and wait to be seen- a significant economic productivity drain for a population that can hardly afford it. This lack of prenatal preventative care could therefore be a major cause of high numbers of deliveries requiring C-section interventions at Queens.
As for the second question, it’s difficult to tell how significant of an impact that these interventions have on maternal and child health outcomes due to a lack of long-term data on the topic at Queens. Surgical operations alone increase risk of infection and sepsis for the mother as she heals post-operatively at the hospital and in the following weeks at home. As mothers recover from the procedure, any complications she experiences can make kangaroo mother care (helping with infant thermoregulation) or breastfeeding difficult. So from birth, babies born by C-section are already potentially at a disadvantage.
But perhaps one of the most interesting threads of conversation on the topic came from the decision on whether to induce labor, perform a C-section, or postpone intervention. At this point, several of the expatriate physicians brought up the fact that the mother rarely, if ever, actually gets to participate in this discussion. Growing up in the American healthcare system, I’ve experienced physician-patient interaction where information exchange and patient agency in decision making are held as central components of treatment plans; however, in what I’ve observed, the doctor-patient relationship at Queens takes on a different focus. Patients almost always default to the physician’s first decision on all treatment plans without requesting that doctors take the time to explain and discuss different options. This difference has been a striking example of how medicine is rarely as culturally neutral as it appears, and the debate on whether patient preference should factor into clinical decisions shows how the exchange of ideas and standards from expatriate doctors has influenced Malawian physicians’ opinions on what the practice of medicine should look like.
For me, informing patients on the risks and benefits of various options and providing patients with a choice seems like the natural course, but this discussion also helped me recognize that my opinion is very much a result of the healthcare system in which I’ve been raised. For a Malawian mother in labor, her preferences for her doctor-patient relationship could be drastically different. For someone used to a system where physicians make most treatment decisions with little patient input, a sudden discussion about her options could indicate to her that the doctor doesn’t feel confident in making a choice; it would be foolish of me to assume that she would want the same experience as me without involving her in the conversation. So while I think that the idea of patient agency in decision making sounds like an exciting discussion for physicians to be having, it also points me back to the importance of conversations with the patients themselves when shifting the concept of the ideal doctor-patient relationship. Regardless of technological advances or cultural exchange of ideas, medicine at its core will always focus on treating and healing the patient, and patient-centered care requires a careful understanding of the specific patient population itself to best treat and heal.