Written by Arielle Randolph, MD, PGY-3 at Kaiser Permanente Oakland Pediatrics Residency Program while on Global Health…
Written by Brittany Kausen, MD, PGY2 at Kaiser Permanente San Francisco OB/GYN Residency Program while on Global Health rotation with Cacha Medical Spanish Institute (CACHAMSI) in Riobamba, Ecuador from April-May 2016.
My first two days were spent in the Ob unit that carries all postpartum (12 cs beds, 12 vag delivery beds), antepartum (alto riesgo 6 beds), and early laboring patients. There are also separate rooms for pre-eclamptic patients that have big black curtains to make them dark with little stimulation – so as not to piss off the pre-eclampsia. Days start with table rounds at 7am followed by walking around seeing patients with the whole team which is a small army. There are approximately 6 interns, 2 resident doctors, one junior attending and Dr. Lino who is the chief. Dr. Lino quizzes everyone — on everything. From pre-eclampsia to doses of antibiotics to units on lab values. The level of training is very different here; interns are more like medical students on their first year of clinical rotations and the residents are more like interns. As a second year resident from the US, my depth of knowledge is probably greater than theirs especially on topics like pre-eclampsia, but having to answer questions in Spanish is a whole new challenge. My first day he quizzed me all about pre-eclampsia – questions I actually knew – but translating it into Spanish was difficult. I somehow got through all of the classification of severe features in Spanish (with the help of a few hand gestures). This really is the best way to learn medical Spanish. I am constantly challenged every day and the same time so intrigued to hear and see how they handle different obstetric situations.
Dr. Lino is very into evidence-based medicine and very eager to hear how we treat patients in the United States. We spend a lot of time exchanging information, web sites and articles in English and Spanish. We both use Evernote which he says is “superbueno.” He loves to open articles and have me translate things for him. His current obsession is magnesium for seizure prophylaxis for mild pre-eclampsia. They have an a amazing amount of pre-eclampsia here. And not just run of them mill pre-E with one sustained severe range blood pressure gets magnesium, but full blown HELLP syndrome. They do a good number of c-sections for HELLP syndrome and severe preE because they don’t feel like they can take the time to ripen a nulliparous cervix which I don’t necessarily disagree with.
The fourth day I spent in the Centro Obstetrico which is where all the births take place. Things are mostly similar to the US with a few choice differences. The delivery rooms are more like operating rooms and they scrub for the deliveries. One of the operating rooms has an enormous braided rope hanging from the ceiling. Since 1990 the maternal mortality ratio in Ecuador has decreased from 185 to 64 per 100,000 live births. This was partly attributed to the Law of Free Maternity and Child Care which was approved in 1994 and codified in 2006. The principle behind the law is that every woman has the right to free, high-quality health care during pregnancy, childbirth and the postpartum period as well as access to sexual and reproductive health programs. This law gives communities the resources to provide women access to health care. High rates of home births leads to high maternal and infant mortality so this is where the rope comes in. The rope is used for a ‘gravity birth,’ an Andean indigenous custom that allows women to give birth in a standing position. The rope was added to hospitals to encourage women from the remote countryside to give birth in the hospital, thus decreasing maternal and infant mortality. It seems to at least be headed in the right direction.
Today I watched a 25 year old and give birth to her third baby. It was a usual multiparous delivery – fast. There were so many people watching the birth. It is a public hospital where the patients don’t pay anything so no bother asking if it is ok if 10 people observe. Everyone just kept calmly telling her to stop screaming. After the birth which the intern of course almost didn’t have his gloves on for, the resident did a manual sweep to remove some small clots for a small amount of trickling. Without anesthesia, the patient was in a lot of pain while her baby cried alone bundled up in blankets on the warmer. She then repeatedly did a currettage with a sponge on a stick while telling the patient not to yell and to not touch her because she was sterile. The patient winced in pain saying “Doctorita” a term used for respect. Going from a private hospital in the US to a public one in Ecuador is a big leap. The San Francisco patient population is demanding and catering to them, I am reminded of my days in the service industry where the customer is always right. That same population keeps me on my toes though because they constantly ask questions, expect a warm bedside manner and furthermore give feedback about their birth experience. In contrast, patients here have so much respect for the doctors to the point that they almost don’t want to bother them. Perhaps when the patients don’t ask for much, we forget to explain things and lose a little empathy. It happens to all of us, I know, but I hope that I will continue to show compassion to all patients regardless whether they are paying or evaluating me.
The culture is of course different here. In the US, we talk to strangers such as our Uber drivers about weather and sports. In Ecuador, they love to talk about politics, if you are married, if you have kids. “Es casada?” “No” <insert jaw drop expression> “Cuantos anos tiene?” “29” <gasps> “Cuando va a casarse?” I love this sequence of questions that happens daily when I meet new people. It’s unfathomable in their culture that I would 1) not be married and 2) not have kids. Of course in the US this can be seen as rude or offensive, but here I just giggle. I have learned to love the expression that comes after I tell them I am not married.
The people are some of the friendliest and most helpful of any country that I have visited. Yesterday on the bus, I was charged $2 for the fare. The older gentleman next to me bumped me on the arm and asked “Cuanto cubre?” (How much did he charge you?). I held up two fingers and he informed me that the fare is actually $1.50. The majority of people stand up for tourists and foreigners because they contribute to the economy of Ecuador. The day prior after getting off of a bus in Latacunga on the way to Quilotoa, a lady announced that she was also going to the bus station where we were going and she would show us the way. She not only escorted us to the bus station but then took us through the station to find the correct bus to our destination. Biking up to Casa de Arbol in Banos, two gentlemen offered us a ride up the huge mountain, throwing our bikes in the back of his pickup truck. He didn’t even ask for money. This would rarely happen in the US and furthermore I don’t think I would get in a stranger’s car in the US, but the people here are so nice that it evokes an inherent trust and comfort.
Today again she asks if Psychiatry will be coming by to see her. She is a 44 year old Para 3 who is 14 weeks pregnant. She has been admitted for 7 days for a “threatened miscarriage” after presenting with vaginal bleeding. Ultrasound on admission showed a live fetus with severe hydrops fetalis and hygroma that offers a bleak fetal outcome. The patient was counseled on the findings and desires termination of the pregnancy. The doctors explained to me that in these cases she has to be seen by Genetics, Neonatology, Psychology and Psychiatry to even be considered for termination. The closest Genetecist is in Quito or Guayaquil, both three hours by car. The family is poor so that is out of the question. She has been waiting for Psychiatry to evaluate her because they decide whether this is mentally distressing enough to warrant termination.
Abortion is illegal in Ecuador. The law in Ecuador provides only three exceptions: a threat to the life of a pregnant woman, or to her health when the danger can’t be averted by other means, and in the case of a rape or statutory rape of a woman with a mental disability. Furthermore, Ecuador has strict prosecution laws for women who seek illegal abortion ranging from 1-5 years with even harsher punishments for medical professional who provide them. The strict laws and criminal restrictions on abortions have serious consequences on women’s health in Ecuador. Most notably it drives women to seek illegal and often unsafe abortions. Human Rights Watch is a nonprofit organization that has studied the impact of Ecuador’s criminal ban on abortion and has concluded that the restriction hinders medical professionals’ ability to detect sexual violence, contributes to Ecuador’s high maternal mortality and morbidity rates and creates delays for women needing potentially life saving care.
To begin, criminalization of abortion affects providers’ abilities to identify and assist women who are victims of sexual violence. Ecuador has high rates of violence against women. According to a national survey in 2011 of 19,000 households, one in four Ecuadorian women has been a victim of sexual violence. Rape victims are more likely to seek abortions and since it is illegal, women are less likely to tell providers that they had an abortion for fear of the consequences. Furthermore, women are hesitant to tell providers about the sexual violence for fear that the provider will come to the conclusion that she had an illegal abortion. This results in missed opportunities for health care providers to refer women to appropriate resources.
Secondly, hindering access to abortions leads to women seeking illegal abortions which contributes significantly to Ecuador’s high maternal morbidity and mortality rates. Abortion is the second leading cause of maternal morbidity in Ecuador. According to WHO, maternal mortality ratio in Ecuador has declined from 160 per 100,000 live births in 1990 to 64 per 100,000 in 2015. Although headed in the right direction, maternal mortality still remains high. This extends to adolescents and girls as well who are more likely to seek unsafe abortions. In 2011, Ecuador estimated that there were at least 286 cases of abortion-related morbidity in girls age 10 to 14 and nearly 4,000 cases in girls 15 to 19. Education regarding reproductive health and family planning is lacking in Ecuador. Adding the barrier of prohibiting access to safe abortion only exacerbates these numbers.
In addition, criminalizing abortion leads to delays in women obtaining good health care. Women present for post abortion care with complications and are hesitant to reveal that they had an abortion. Some health care providers will even refuse to provide care to women who they suspect have had an abortion due to fear of prosecution. Human Rights Watch interviewed providers who said that women and girls come in bleeding, sometimes with infections, but will offer little information. This undermines the provider’s ability to provide efficient quality care.
Many groups such as Human Rights Watch, the United Nations as well as Planned Parenthood Global have encouraged Ecuador to reform its abortion laws. President Rafael Correa went as far as to threaten his resignation in 2013 if the National Assembly passed an amendment to allow abortion in cases of rape. He upholds that life begins at the time of conception and thus should be protected from then on. In 2015, the UN Committee on the Elimination of Discrimination Against Women urged Ecuador to decriminalize abortion in cases of rape, incest and severe fetal impairment, but the law remains unchanged.
When asked about the abortion law in Ecuador, the doctors of the Hospital General where I am working express their frustration. They are also aware that illegal abortions are extremely common all around them. They seem to unanimously believe that in cases of severe fetal impairment such as in this case, the woman should have the right to terminate the pregnancy. So this morning we had a meeting with all of the attending obstetricians and one pediatrician as well. After psychiatry saw the patient and stated that the situation was now affecting her mental health, they decided as a group that they felt comfortable terminating the pregnancy at the patient’s request. All 7 of the attending physicians signed a document stating that they universally agreed to termination in this case. The patient was brought in and informed of the decision. Her response was tears of joy as the thought of having to continue carrying a fetus that would have no meaningful life was unbearable to her. She underwent induction termination under the proper supervision of medical personnel. In this case, the doctors truly advocated for the patient with passionate interdisciplinary discussions and now the patient can move on.
I can’t help but selfishly consider the present state back home in the US where women’s access to abortions is currently being threatened. Restrictions in states like Texas have already affected many women. Criminalizing abortions leads to devastating consequences and forces women to seek clandestine unsafe abortions. Hopefully the US will continue to serve as a role model in a woman’s right to choice and access to safe and reliable health care.