November 15, 2007

Hand-Holding Doctors
Lima, Peru

What I want in a doctor, infant mortality rates, and a US$23 Peruvian ultrasound in Lima.

I think Tatiana has experienced a greater breadth of maternity treatment than the majority of mothers-to-be out there. Since April, she has been examined in the United States, Egypt, the Philippines, Cambodia, and Peru. She has had ultrasounds conducted in all these places, and sought the advice and consult of practitioners communicating in languages that were not their native tongue.

Save for Egypt and the USA, I've accompanied Tatiana to each of these visits, and because of it have formed opinions about what I want to see in a maternity consult. By far and away the worst of the bunch for me has been Tatiana's visit here in Lima.

What I want to see in a doctor is leadership. I don't necessarily want him/her to dominate the conversation, but I want a confident physician to know the steps, know the tests, and know exactly what has or hasn't been done to his satisfaction. I want Tatiana's doctor to be speedy, but not make us feel like we're being rushed out the door. I want our questions answered competently and completely (with an explanation behind the answer).

What I hated about Dr. Saul Chauca Berlanga at Centro Medico San Judas Tadeo was the posturing and hand-holding that I felt like I had to do with the man. It was pissing me off to watch this guy look at her test results (in languages he had no understanding of) and nod his head while pointing at numbers saying "si, si, bueno." I could've handed her previous lab work to a bum on the streets and gotten the same level of feedback.

Sitting in the consultation room with Tatiana, I really wondered if anything productive was going to be accomplished. For the first time in her pregnancy Tatiana was able to communicate with the doctor in the mother-tongue, yet I felt like it was just a waste of time.

I turned to Tatiana and said, "I'm not paying this guy to nod his head at your paperwork. I want you to be examined. I want direction. I want to know what tests we've missed, if any. I want to know what tests we need to have run. Why do we have to tell this guy what we want to know? I don't care that he has to normally posture for people that don't know what's going on. We do, and this guy is full of it."

We'd already been in there 10 minutes, with nothing accomplished. Tatiana told me things take more time here—with over a year already spent in Latin America, I'm familiar with the speed of things—but that still didn't make me feel like we had to tell this doctor what to do with us next.

At one point I had Tatiana read off a list of the tests that were run over the course of her pregnancy, in an attempt to get some laboratory direction of the guy. I don't know if doctors are always so hands-off at this stage of the pregnancy—I want to use the term laissez-faire—but there has to be more to do at the seven-month mark than another ultrasound and piss test.

On the subject of testing, I was going back and forth with Tatiana this morning about getting a glucose tolerance test. Information my brother in med-school had sent us indicated it should have been done in weeks 24–28, and seeing as we were in week 32, it was wildly overdue.

I'm a strongly opinionated person, and don't really hold back with my feelings on things. An hour or two after the fact I had to apologize to Tatiana, and tell her my insistence on doing the test was just me expressing concern about her health and the health of the baby.

She doesn't want to get the test, as she thinks it's unnecessary. In a heat of the moment comment, she said there's more problems with pregnant women in the United States, and that's why they need more things done. "Just look at how many obese people there are."

"Are you kidding?", I responded, "There are hoards of obese people in Peru, and the rest of Latin America! I've seen plenty of them."

"Besides," I continued, "there's a reason that infant mortality rate of Peru is over 450 times that of the United States. The tests are important."

Infant Mortality Rate (Male)/1,000 Live Births:

  • USA: 7.02 deaths
  • Peru: 32.47 deaths

Out of curiosity, I looked at the infant mortality rates for the region of the world we'd just traveled through. These figures make me very happy we would not be delivering in SE Asia, though I found the quality of maternity care in the Philippines and Cambodia to be quite satisfactory (though the numbers tell a different story):

  • Singapore: 2.5 deaths
  • Malaysia: 19.26 deaths
  • Thailand: 20.13 deaths
  • Vietnam: 24.76 deaths
  • Philippines: 24.85 deaths
  • Indonesia: 37.39 deaths
  • Burma: 57.33 deaths
  • Cambodia: 65.74 deaths
  • Laos: 90.91 deaths

And for a more comprehensive comparison, a selection of countries that randomly popped into my head:

  • Japan: 3 deaths
  • Switzerland: 4.77 deaths
  • Greece: 5.87 deaths
  • New Zealand: 6.48 deaths
  • Panama: 17.33 deaths
  • British Virgin Islands: 18.82 deaths
  • Egypt: 31.22 deaths
  • Maldives: 52.4 deaths
  • Togo: 66.56 deaths
  • Afghanistan: 161.81 deaths

Tatiana eventually agreed to get the test, but when we found out they only offered the second-stage three-hour exam, I decided to back off. Looks like that's one that won't be getting done.

We did have an enjoyable US$23 ultrasound session today though. The technician operating the equipment (which looked like piece of technology that was less advanced than we we saw in the Philippines, but better than Cambodia) spent a half an hour with us, made a DVD of her session, and provided us with all the answers and information we wanted to know.

I'm not sure how other fathers-to-be feel about the ultrasound, but I have zero interest in seeing the Doppler image of a half-melted baby on a screen. (laughing) Sorry, but all I really care about is the health of the child and the measurements obtained during the session. I know Tatiana (and other mothers in her position) love seeing what's going on inside their bellies, but the idea of something gestating inside her abdominal cavity continues to creep me out to no end.

Tatiana asked if my dad would like to have a copy of the DVD, and I said "if he's anything like me on the subject, I doubt it. My step-mom would probably be interested, but I don't think dad would really care (to watch)."

The DVD was nice to have though. It allowed Tatiana to share the results of her ultrasound with her family tonight, and laugh at each other as they attempted to guess body parts and the such. Tatiana was speculating earlier that her mother is feeling uncomfortable about the fact she isn't the one in the examination room with the doctor, or at the ultrasound visit with her. Tatiana's mom is so use to being a controlling part of the family, that this position in the hierarchy is certainly new and unusual for her—though has made no attempt to try and include herself in places I'd rather be with Tatiana alone.

So, I think what's important at this point is to establish a rapport with the practitioner that's going to operate and deliver the baby as soon as possible. Tatiana's familiar with the clinic that her brother's Fiancée delivered at (twice, by c-section), and wishes to give birth there as well. After the follow-up to review the lab results (tomorrow?), I want to stop all this doctor-jumping and finish the reminder of Tatiana's pregnancy—about 45 days now—with routine examinations/consultation from consistent physician.

It's amazing how fast time passes…


Tom Heimburger

November 16th, 2007

Actually, I'm really enjoying seeing the ultrasound images. No DVD necessary, but keep the pics coming!


Craig |

November 16th, 2007

Yeah, I thought not. :)


November 16th, 2007

"…but the idea of something gestating inside her abdominal cavity continues to creep me out to no end." LOL!

I don't think you were out of line demanding the glucose tolerance test. Gestational diabetes has nothing to do with diet. It occurs in 5-10% of pregnancies (obviously, in women without diabetes to begin with). Women who are older, of ethnic background and have a family history of diabetes are at an increased risk.


November 17th, 2007

no, we dont have diebetes on our family, at least for the side of pur mom´s..
a risk is higuer also when the woman is overweigh specially by the time of getting pregnant, and thats not Tatiiana´s case…
So, yes… too bad i cannot send my doctor from here, he´s the best! but relax, everything will be fine! ;)


November 17th, 2007

Hey Craig! To be looking at health care during pregnancy and around the neonate period, you need to look at indicators such as Neonate mortality and perhaps more importantly the Perinatal Mortality. The second indicator represents in underdeveloped countries the (# of deaths -from 28 of gestation to 6 days of life) x 1000) divided by the number of live births. In developed countries, you add the number of deathbirths to the denominator. You probably could find these two indicators for a variety of countries.

The indicators you listed include deaths from birth to one year after birth. They reflect more economic conditions, malnutrition, education, hygiene and medical care post-birth. When they are high, the indicate unmet sanitary needs and a unfavorable environment.

Good luck with the baby!

Josée de Montréal, fresh from taking an epidemiology course…yep have to take those too in med school


Craig |

November 17th, 2007

An excellent contribution Josée! I didn't know about this statistic…

Taken from the WHO (World Health Organization): Neonatal deaths account for a large proportion of child deaths. Mortality during the neonatal period is considered to be a useful indicator of maternal and newborn health and care.

Definition: Number of deaths during the first 28 completed days of life per 1000 live births in a given year or period.

Neonatal mortality rate (/1,000 live births), as of 2004:

USA: 4 deaths
Peru: 11 deaths

Singapore: 1 deaths
Malaysia: 5 deaths
Thailand: 9 deaths
Vietnam: 12 deaths
Philippines: 15 deaths
Indonesia: 17 deaths
Laos: 30 deaths
Cambodia: 48 deaths
Burma: 49 deaths


Craig |

November 17th, 2007

Complications during pregnancy and childbirth are a leading cause of death and disability among women of reproductive age in developing countries. The maternal mortality ratio represents the risk associated with each pregnancy, i.e. the obstetric risk

Definition: Number of maternal deaths per 100,000 live births during a specified time period, usually 1 year.

Maternal mortality ratio (/100,000 live births), as of 2000:

USA: 14 deaths
Peru: 410 deaths

Singapore: 15 deaths
Malaysia: 41 deaths
Thailand: 44 deaths
Vietnam: 130 deaths
Philippines: 200 deaths
Indonesia: 230 deaths
Burma: 360 deaths
Cambodia: 450 deaths
Laos: 650 deaths

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