In 1926, anthropomorphic teddy bear created by A. A. Milne called ‘Winnie-the-Pooh’ said, “A grand adventure is about to begin.” A wiser, sager, greater man two and a half millennia ago had a more profound take on birth and life. In his time, his views were both controversial and esoteric. Today we call it science. It is ironic because a man whose own birth was laced in such dreamlike mythology would bring forth a biologically sound classification of the process of birth.
According to Gauthama Buddha, the elements of chittha (mind), cheithasika (consciousness) and rupa (matter) unite to bring forth a new life. This is called pattisandhi (conception). Pattisandhi is classified into four types depending on various kinds of past karma, as opapathika, samsedaja, antaja and jalabuja Pattisandhis.
The conception of human beings in the wombs of their mother is Jalabujapatisandhi – a life in water sac. Once a baby is conceived, the baby and the mother go through a number of phases. Baby grows and changes dramatically throughout the pregnancy. Mother also goes through many changes during each stage of pregnancy. At 28 weeks, both the mother and the baby enter into a significant phase – third trimester. Fetel development continues during the third trimester. The baby will open his/her eyes, gain more weight, practice breathing and prepare for delivery. A number of changes take place in the mother physiologically and several medical complications may develop. Following the intrapartum period, a baby is born. The first seven days of life are crucial for both mother and the newborn.
From 28 weeks to seven days after birth is called the perinatal period. The “perinatal” period originates from Greek peri, “about, around” and Latin nasci “to be born” – this is “around the time of birth”. The science dealing with perinatal care is called perinatology. Perinatology focuses on managing health concerns of the mother and foetus prior to, during and shortly after pregnancy.
Perinatal care in Sri Lanka
Sri Lanka’s maternal and child healthcare service delivery is so successful that the country has a maternal and child health record that is the envy of South Asia. Nowhere is this better reflected than in the Maternal Mortality Ratio (MMR). The MMR declined over the years in Sri Lanka. In 1948, 1,700 women died when 100,000 babies were born alive.
Data shows the reductions in maternal deaths in successive years. In the year 2015, there were 113 maternal deaths and 334,841 live births to report an MMR of 33.7 per 100,000 live births. In other words, 34 women die when 100,000 babies are born alive. This is an inspiring success when we compare with regional countries and the global worst. We are well-placed along with global best MMR countries (Finland and Greece) and other comparative countries (Thailand and Malaysia).
However, with Sri Lanka’s current MMR status in comparison with the global best and countries with similar socio-economic levels, we have a long way to go to achieve a single digit MMR. Reviewing maternal deaths will do nothing. Translating lessons learnt into policies, programmes and practices is also of utmost importance. We have done a multitude of actions as lessons learnt out of maternal deaths. From 2007, over eight years, the country’s MMR fluctuates at a same level.
A significant reduction is not evident. The cause of maternal death profile shows 65 per cent medical complications especially heart diseases and pneumonias. Our caesarean section rate is 34.5 per cent in 2015 and the induction rate is as high as 33 per cent. An in depth analysis into such high rates has not so far been conducted.
The infant mortality rate also reduced over the years to reach 8.2 per 1,000 live births in 2013. When translated into numbers, it is nearly 3,030 babies dying before their first birthday in a year in this country. Seventy one per cent (2120) of these deaths are reported in the neonatal period, within 28 days. Out of neonatal deaths also 60 per cent (1,270) take place in the first seven days of life. Contributory factors of such deaths originate within the continuum of care received by the mother and the baby in the latter part of the pregnancy, at birth and the early neonatal period. It is obvious that further prevention of infant deaths necessitates focusing on care during birth and in the immediate neonatal period, the perinatal period.
Deaths in perinatal period
Deaths in the perinatal period, stillbirths and early neonatal deaths, provide an insight into the quality of antenatal and perinatal care. More than five million perinatal deaths occur globally each year. Sri Lanka did not have solid perinatal data in the past.
In spite of the health of our pregnant women, foetuses and neonates improving to a commendable degree over the past few decades, much remains to be done in the field of perinatal care.
Priority areas in perinatology
Several activities can be identified as means for improving perinatal care, in order to reshape the care for the pregnant women, unborn babies and newborns.
* Transfer knowledge: Raising awareness among the medical community and general public on perinatal care and related issues
Promotion of better understanding between doctors and patients and promotion of closer co-operation among all categories of health professionals as well as between the state, the society in general and its individual members, are all factors that will ensure continued improvement in the health of our people. The Perinatal Society of Sri Lanka (PSSL) acknowledge that a greater understanding of health-related issues by the medical community itself and the public would help to improve the standard of perinatal care. The Perinatal Society of Sri Lanka will conduct Media seminars and parent crafting meetings to achieve such targets.
* No more deaths: Prevent maternal and perinatal deaths
Two strategic plans, The Every Newborn: An Action Plan to End Preventable Deaths (ENAP) and Ending Preventable Maternal Mortality (EPMM), aim to catalyze global action to eliminate wide disparities in the risk of death and end preventable maternal and newborn mortality and stillbirths within a generation.
Ending preventable maternal deaths, stillbirths and neonatal deaths will continue to form a significant part of the international public health agenda beyond 2015. In such a context, the PSSL will support: Maternal death surveillance and translating lessons learnt into action; maternal near-miss surveillance – the next level quality approach in maternal care; establishing highly-specialized obstetric centres and promoting real multi-disciplinary approach; improved perinatal care.
* Continue current work: Support the activities already launched by the PSSL
Training different categories of staff engaged in care-in and around delivery is essential for better outcomes. In caring for newborns in neonatal intensive care units, over 60 per cent of the work is done by nurses. PSSL will continue to conduct emergency obstetric care for labour room staff and Neonatal ICU Nurse Training Programme.
* Intricacies in Newborn care
There are numerous sophisticated therapeutic modalities introduced in sick newborn care. The Therapeutic Hypothermia is now the gold stranded Rx for Hypoxic-Ischemic Encephalopathy (HIE), not yet available in Sri Lanka, except at Castle Street Hospital for Women. HIE incidence is three to four out of may be even more adding to mortality and morbidity of newborns.
A significant portion of deliveries end up with preterm babies. Total parenteral nutrition is important for optimal nutrition for sick babies. Caffeine is a respiratory stimulant for preterm babies. All these are not yet available for management of preterm babies. The PSSL will advocate for making available such therapeutic approaches in the country.
* Counting for action
The first step in formulating preventive strategies on perinatal mortality is the accurate capture of all perinatal deaths and classification of the causes of those deaths across all settings, using a globally applicable and comparable system. Sri Lanka initiated using ICD-PM classification advocated by the WHO from January 2016.
* Writing the vital event
Not only the counting, registering the vital event is also important. The gold standard source for mortality data is from the civil death registration system. PSSL council will facilitate registration of stillbirths and early neonatal deaths with the Registrar General’s Department.
* Knowing the unknown
For many perinatal deaths, a valid cause was not available. Knowledge on the unknown cause of death is crucial. The PSSL in collaboration with the Family Health Bureau and College of Pathologists will facilitate the availability of guidelines and equipment for pathological post-mortems on perinatal deaths.
* Addressing the unaddressed
The other aspect not much focused on is the genetics due to various reasons. Strengthening the genetic component in perinatal care will be supported by the Human Genetics Unit, Faculty of Medicine at the Colombo University. Exploration into genetic causes should begin on day one itself. The areas of genetic counselling training, establishment of counselling centres and advocacy on geneticist training are on the card.
* Adding humanity: Rights-based approach in perinatal care
Ending Preventable Maternal Mortality (EPMM) targets and strategies are grounded in a human rights approach. In a framework of patient-centred care a humane approach is fundamental. Adding the dimension of rights-based approach will undoubtedly improve the quality of perinatal care.
* Looking at the disability
Neuro developmental care for the new-born is another area fairly neglected. The PSSL will touch on early intervention of the risk of new-born, early detection of neuro developmental delays, prompt and timely referral to specialised care and multi disciplinary team approach in such cases.
* Explore methodically: Research into perinatal care and issues
To improve maternal survival and pregnancy outcomes, it is important to provide adequate obstetric care, including optimal timing for delivery in high-risk pregnancies. Optimal timing of delivery is ideally the gestational age at which the risk of adverse maternal and neonatal outcomes is minimized. An area of concern is the ever-increasing induction and caesarian section rates. Considering the need for solid data, a structured study into factors contributing to high caesarean and induction rates will be conducted.
The entire world is on the alert for the Zika virus. Sri Lanka has also initiated several approaches to face an impending threat of Zika. Microcephaly surveillance is advocated by WHO. To explore whether Zika virus is responsible for microcephaly, in sub-Saharan and Asia, The Institute Pasteur proposes to set up a surveillance system for microcephaly in several large urban maternities of Aedes-infested regions of SSA and Asia. Cases detected through the surveillance system would then be explored for common genetic and infectious causes and the proportion of microcephaly attributable to ZIKV would be determined. Last week, the PSSL was able to include Sri Lanka also in the study.
* Mixing technology
As time passes, it would become increasingly difficult not to take note of the great technological advances made in the fields of information and communication technology (ICT) and its application in perinatology. These advances are rewriting textbooks and transforming medicine and the way health care is delivered. As much as antenatal care, skilled birth attendance and improved neonatal care, helped us conquer maternal and perinatal deaths, ICT and genomics are the weapons that will help us conquer further reduction of mortality and improve survival of pregnant mothers, unborn babies and neonates.
(The writer is a Consultant Community Physician and the President of Perinatal Society of Sri Lanka)