The other day here in Australia, I was with a friend in town when her daughter called her, panic-stricken after being bitten by a snake at their home 10km from town. As I sat on the phone with Emergency Services, who answered on the first ring, replying to their orderly and systematised questions, my surprisingly calm friend drove us home. We followed organised traffic past well posted speed signs on sealed roads. Within minutes of our arrival a distinctly marked emergency car with one paramedic led a fitted-out ambulance with two more paramedics into the driveway, sirens blazing. They calmly entered the home wheeling a shining stainless steel, adjustable stretcher with a fitted mattress and carrying custom-made bags organised with various first aid equipment. Their assessments and treatment were methodical, calm and professional. Moments later the local snake handler arrived, photographed the bite site to help identify the species of snake he should look for, and took his snake hook outside hoping to capture the culprit (alas, to no avail).
Once stable the patient was rolled onto a sheet, the stretcher was lowered smoothly to floor level and she was lifted onto it. A clip of a switch lifted it to normal height and she was wheeled out to the ambulance, where the stretcher clicked onto a hydraulic system and manoeuvred into the ambulance cab with minimal manual effort. The vehicle was equipped wall-to-wall with state-of-the-art emergency apparatus and appropriate seatbelts to ensure the comfort and safety of the patient and other passengers. In the Emergency Department she had her own private, shining clean, spacious cubicle with two doctors and two nurses hooking her up to monitors and inserting intravenous lines, all following well-established and evidence-based protocols. After a few unsuccessful attempts at intravenous cannulation the doctor disappeared briefly, returning with a mobile ultrasound machine to help him locate a vein. Mum and daughter were well informed about every procedure and every discussion between the team included them.
Not only are all of the bells and whistles available in our health services, but our health professionals have received first world, advanced training, with regular professional development to ensure practices remain up to date. They work in teams so that no single person “owns” all of the information, nor all of the power in decisions made about patient care. This does not mean that mistakes are not made, but all of these very first world aspects to health care reduce the chances of error significantly. Every health professional we encounter earns a salary allowing them to feed their families, pay off mortgages or afford rent, furnish homes, take out loans on motor vehicles, go on regular holidays and various other first world “needs”. Not one requires, nor works in a system which allows them to ask for or expect, cash payments from the patients in their care.
In comparison to this experience, images of the “Emergency” ward in Cambodia flashed in and out of my mind like waves crashing to shore. Memories of a nurse at either end of a canvas fitted through two rusty poles, bearing half-shares of the patient’s weight as they ran their stretcher hurriedly across uneven gravel, past leaking sewerage pipes and stained, dirty concrete walls. Passengers sitting unrestrained on the bare floor of a mini van with an almost comical siren squealing from it’s roof, a single red strip across the vehicle’s centre identifying it as some sort of ambulance. Patients lying in rows of steel beds without mattresses, surrounded by others lying on hard concrete floors, with dust and dirt and grime in every nook. An immobile elderly patient clambering out of bed onto a floor-level toilet pan in plain sight, sound and smell of at least 30 other people. Stepping over crowds of sick bodies mingled with newborn babies. The complete lack of anything remotely resembling a monitor. Bags of fluid hooked onto the ends of bamboo sticks. A malnourished elderly man, ribs sucking in and out with each breath, in desperate need of unavailable oxygen, his only relief a wet cloth patted on his forehead by a doting daughter. Nurses dressed in white from the caps on their heads to the shoes on their feet, reminiscent of 1920s Australia.
Photographing my friend sitting in the ambulance with her daughter, she shouted out to me “You’re not in Cambodia now!”, explaining to the paramedics that I had “just come back from living in Cambodia”. The snake handler turned to me and said “you have to try quite hard to die from snake bite in Australia but the opposite can be said for places like Cambodia”. No truer words were spoken, and snake bite is only the tip of the deathly iceberg!
Financial Times reporters on three continents follow the fates of three women and their babies in this report on childbirth in poor nations at Three Births
Last year when Chom’s wife was having their second child, and again this year as Samantha approached the birth of her second child, I found myself increasingly exasperated by both couples’ apparent ill-informed and irrational medicalised approach to childbirth. Chom’s wife had miscarried previously and Samantha’s first child is her now-2.5yo son who continues to exist with a severely debilitating, ultimately terminal, genetic condition for which the only care he receives is from his impoverished family. Even so, the apparent obsession both couples expressed about medical interventions seemed bewildering to my first world brain, which knows that excessive medical interventions are more likely to be harmful than helpful in normal pregnancies. The talk from both couples included innumerable ultrasound scans for no apparent reason and excessive talk about caesarean sections, all of which are costly and unnecessary interventions. Given my descriptions herein of the public hospital experience it was no real surprise that both sought obstetric care in a private clinic, but the lead up to both births left me flummoxed at how medical it all seemed, for no credible reason.
Visiting Chom’s newborn at the private clinic, some of my puzzlement fell into place. A beautiful building in comparison with any public clinic or hospital, although equally as crowded with newborn babies and their families squeezed into every space in foyers and along open corridors. Chom paid extra for a private room which was furnished elaborately with a private bathroom, air conditioning and a television. Superficially, everything looked superior to the alternative and I understood why private clinic was considered the best choice. However, these clinics are run as profit making enterprises by the doctors who own them. Medical interventions paid for by the client are highly profitable, including ultrasound scanning and caesarean section, so I came to understand why such interventions are promoted as “best care” when in fact, they are quite the opposite.
Cambodia’s health literacy is led by private-clinic-owning doctors, in a population crippled by poverty whose young adults of today are a single generation away from the complete destruction of the country’s education system. The promotion of unnecessary and often risky interventions to paying clientele, in a country with no malpractice liability and low health literacy, is hardly surprising. With a lack of access to alternative reliable information, it is also unsurprising that their clientele believe what they are told by wealthy and successful doctors working out of superior health facilities. Even so, most Cambodians cannot afford to attend these clinics, and childbirth usually takes place either at home or in public facilities. This is likely the only reason that the caesarean section birth rates are as low as they are, at just 3%.
Caesarean section is major surgery with many associated short and long term adverse effects, from wound infection and infertility in the mother, to feeding difficulties and lung problems in the baby. The World Health Organisation recommends caesarean sections only be performed when medically necessary, and has stated that there is no justification for C-section rates to be any higher than 10 to 15% of all births in any given region. The outcomes for both mother and baby are generally much better when childbirth occurs naturally, except for those rare cases where C-section is indicated for medical reasons. Despite this, there has been a profound upward trend of caesarean births in wealthy nations. When first measured in 1965, the national C-section rate in USA was 4.5%. In 1991 Australia’s national C-section rate was 18%. Today both countries record C-section birth rates of around 32%. The rate in Australia’s private clinics rises to 43%.
It is difficult to pinpoint exactly what leads the upward trend towards caesarean sections and doctors appear to give different reasons than midwives, for the pattern. Two medical reasons given, which are not relevant in poor nations such as Cambodia, include the increase in age of mothers and the increase in obesity, both of which are more likely to be associated with an indication for C-section. Many doctors also claim that women are increasingly asking for C-section while midwives have claimed that women are subtly coerced by obstetricians, whose training is almost entirely related to abnormal pregnancy and surgical intervention, to consider C-section as a preferable alternative. Midwives also argue that most women who deliver by C-section do so despite not wanting to. While there are no direct financial incentives in Australia for performing C-section, scheduled elective surgery does allow doctors to take on more clients, so there is a definite indirect financial benefit to the doctor when women choose C-section. Another determinant in a country like Cambodia, is likely the observation from afar, of the rising popularity of this intervention in wealthy countries. We are, after all, shining examples of health care, to be emulated wherever possible!
In the lead-up to the birth of Samantha’s second child, she was given multiple reasons for the recommendation of caesarean section birth, none of which held up well to proper scrutiny. She has always claimed that her first child was born after a difficult and lengthy labour. However, upon questioning it appears that in fact, she had not progressed to labour yet, when an emergency C-section was determined necessary. She blamed her son’s neurological condition on this “difficult labour” for many months. When we were in Seattle together with Paula my very kind friend arranged a consultation with a paediatrician who determined that his condition is in fact genetic and nothing to do with anything that happened during pregnancy or childbirth. Nevertheless, she was understandably anxious about the second birth, this time of a girl who will not be afflicted by the same genetic syndrome.
She underwent multiple ultrasound scans during pregnancy and from a very early time began speaking of caesarean section. The reasons given at differing times included: previous C-section as an indication for future C-section (this is incorrect, and trial of labour is normally recommended for women who have had one previous C-section); breech presentation on scan at 34 weeks pregnant, when a large proportion of babies have not yet turned (and when scan is not indicated); nuchal cord (umbilicus around the neck) on another scan at about 38 weeks, which is an extremely common presentation and not considered to be associated with adverse events during normal vaginal birth. Each of these reasons suggested that she was either looking for a reason to have caesarean section, or being coerced by her private doctor to believe it was the best option. She said things to me such as “I must do the right thing for my baby, so I should have a C-section”.
Each time she returned from her (many) medical appointments, she presented a new reason for C-section birth. When I and my midwife friends explained away each pseudo reason, she would present after her next appointment with a new medical “reason”. Finally a midwifery lecturer friend and I met with her by video conference to speak at length about the reasons that normal vaginal birth would likely have better outcomes for both baby and mother. In no small way did one of these reasons include a financial saving of many hundreds of dollars. She appeared convinced and we felt we’d done a very good deed for a young family.
On the due date she presented to hospital with pre-labour pains and was informed that she had appendicitis and needed an appendicectomy! As they must operate anyway, they would deliver the baby by C-section at the same time! With so much persistent talk about C-section over so many months, and an absence of any symptoms of appendicitis except abdominal pains, this reeks to me of fabrication and her family will be paying their surgical debt for months if not years to come. With the severe damage done to Paula’s gastro-intestinal system by over-zealous and obviously unqualified surgeons, the thought of agreeing to abdominal surgery in Cambodia fills me with horror and I was glad that I only learned of Samantha’s fate after the event. She is now home and apparently recovering.
Associated with this topic, is the issue of breastfeeding versus artificial feeding. In the 1970s the World Health Organisation introduced an international code of marketing for infant milk substitutes. This followed the scandal of formula companies, most famously Nestle, unscrupulously promoting their products to impoverished mothers. Hundreds of thousands of babies died unnecessarily in third world countries, and many more suffered malnutrition, disease and permanent stunting. because of this rampant corporate exploitation. The scandal was first publicised in Mike Muller’s 1974 report, The Baby Killer. It is one of the most infamous public health scandals of the 20th century and led to Australia’s very strict rules around baby formula and all baby products, which cannot be sold or advertised in the vicinity of facilities providing care to pregnant or post-partum women. I studied this scandal in detail, understanding exactly why, as Nurse Manager of a Paediatric Ward some years ago, I had to be vigilant to the presence of anything that could appear to be marketing any kind of baby products whatsoever in our hospital, down to health promotion materials even mentioning the name of certain corporations.
Last September when I walked into the maternity clinic to visit Chom and his new baby, I was stopped dead in my tracks inside the main door, by the sight of baby formula and bottled water stockpiled from floor to ceiling! Across the foyer was a second shop, stashing every imaginable baby product from powders and soaps to strollers and cots. Chom’s new son had arrived by normal vaginal birth without complication. Immediate skin-to-skin contact with Mum is recommended to promote breastfeeding and he explained that this had happened but after five minutes, baby was whisked out of the room and handed to Dad and grandma “because they had to make sure <mum> was okay”. Mum was perfectly fine and there was no other reason given for her to be separated from her baby, making me wonder at why, in a maternity clinic blatantly promoting baby formula, this separation appeared to be normal practice? The baby screamed incessantly for a prolonged period and because he was so hungry his grandmother finally sent Chom downstairs to purchase water and milk powder so that he could be fed. How calculated and convenient it all seemed! The scandal which was so widely publicised in the 1980s, appears to me, to be proceeding unabated in countries where people are ill-informed and powerless, and where practices are poorly monitored, if at all.
On my arrival at the clinic I asked Chom’s wife if I could please photograph the bottled water and formula to send to my friends in Australia “because they would be so shocked”. Chom said “this is normal in Cambodia, it is okay”, looking slightly dumbfounded at my reply which went something like “it is absolutely not okay, it is babies in poor countries who suffer because of formula feeding”. That day he and his wife decided to discard the formula, despite having paid for it and planned not to let it go to waste. As far as I know, his baby was then exclusively breastfed, although I know that they introduced solids much earlier than recommended, relying as so many do, on their own ideas about what to do, in the absence of any proper information. WHO describe breastfeeding as “the normal way of providing young infants with the nutrients they need for healthy growth and development. Virtually all mothers can breastfeed, provided they have accurate information, and the support of their family, the health care system and society at large…. Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond“.
It disappointed me this week, after relaxing when I heard that her baby was breastfeeding well, to hear Samantha say “because I don’t have enough milk, I get formula for her too and she will have both”. This is contrary to the well established evidence that breastfeeding stimulates milk production and adding formula feeds ensures the failure of breastfeeding for many known physiological and psychological reasons. Again, my first world brain was horrified and I gave a strongly worded response, asking if the clinic sold formula. Possibly afraid of giving the wrong answer, Samantha did not reply to this question. The answer is surely yes!
It is astounding to see this promotion of artificial feeding for no reason other than what appears to be profiteering, in a population who can ill afford the extra unnecessary expense. This is even more shocking when malnutrition, infectious diseases and ill health already dominate peoples’ lives, all of which can be prevented in the first months of life by exclusive breastfeeding.
The dangers associated with childbirth in developing countries appear to have opened up a market of unethical practices, such as promoting surgical intervention and artificial feeding as the best choice for mothers and babies, all because these have a much more profitable result for the facilities providing care. The general population are in a vicious cycle, aware through close hand experience, of the perils of childbirth, therefore wanting the best. “The best” appears to be available from private enterprises who prosper from implementing bad practices, ultimately resulting in worse long term outcomes for mothers and babies? The debt of a mother who dies in childbirth will not be forgiven, and widowed fathers and extended families can spend years trying to repay money owed to clinics responsible for their loved one’s death or disability. There was no better example of this, than Paula, whose repeated surgeries were not pregnancy-related. Her intestines were quite literally hacked to pieces and she was sent home to die, her family left in severe debt to the people responsible. Their search for a “cure” resulted in severe disability leading to a slow and painful death, and a debilitating family debt.
Some of the indicators in reports by UNICEF and WHO, for positive maternal and neonatal outcomes, include such things as the number of facilities offering peri-natal care, per head of population. With what I have learned about the private facilities and their focus on profits, I wonder if this necessarily equates to positive outcomes? As most pregnancies are normal and healthy physiological processes, could it be that poor villagers who have no choice but to give birth at home, might in fact be ultimately better off than people who have the capacity to take out loans for private health care? The examples of Chom and Samantha alone, would suggest so. When I told Win some days after my visit to Chom’s family at the maternity clinic, that I had stood on the stairs and photographed the clinic shops, he replied “that is why they do not like foreigners to go to their clinics, because you know too much and it can cause problems for them”.
When I feel exasperated by some of the behaviours of my friends, particularly around health care, I have to remind myself consciously of the comparison between our experiences and perspectives. As someone from the rich and privileged world, I know what is best from my educated and unexploited place in the world. That does not mean however, that I am in a position to judge the behaviours of those who only know adversity that I have never even had to imagine. Figuratively speaking, it is all too easy to condemn the behaviour of those floundering in bare feet on jagged stones as we amble comfortably along soft terrain at lofty heights with an unlimited choice of footwear. It is also, as Herman Melville said, preposterous of us to do so.