Tuesday, October 23, 2012

A Snapshot of Birth in Panama City, Panama

Dear readers,

This summer I traveled to Panama as part of a graduate course on women's health. During our time in Panama City we visited numerous health clinics, hospitals, an oncology center, health ministries, and institutes related to health issues that affect women internationally such as domestic violence, cancer, infertility and maternal health, sexually transmitted infections, sex trafficking and refugees, and more.

One of ours visits was to a maternity care hospital that was publically funded by the Social Security system. In Panama, health care is funded either by the private system (individually purchased, more pricey) or by the government. The public sector is funded through the Ministry of Health and the Social Security System. Your health care options are greater if you have the money to purchase private health insurance, but the public sector takes care of the majority of Panamanians.

We met and spoke with a doctor who assessed women for infertility and provided infertility treatment. Below is one of her exam rooms, with the sonogram machine. Notice the brown paper on the bed - this is what the hospital used because they didn't have nearly enough absorbent chux pads for all the women.

On our tour of the maternity care hospital, we were led through some of the postpartum floors. On these floors there were several "areas" which held about 14 beds in each section, side by side. This is where the women would recover from their births and be with their babies. Just to reiterate: these were not private rooms. And they were not entirely closed off to the central wide hallway where the nurses station was located. The women could walk around the hall with their babies - we saw some of them on these floors, though none of the areas were near full.  There were some great bulletin boards on these floors:
Then we went to the labor and delivery floor. From the small lobby, which was full of rocking chairs, we could see new moms standing in the hall waiting to receive their babies from the nursery through a small window in the wall. It reminded us of a fast food drive-through window! As mentioned previously, the women did room-in with their babies postpartum. On this floor there were two small postpartum areas - one for the moms with normal low-risk births, and one for moms who had been higher risk (i.e. preeclampsia).
postpartum room on the delivery floor

We didn't think we'd be able to go back into the labor and delivery area, just as we weren't allowed to enter the floors where women were recovering from surgery. But then the doctor came out and said "I have clothing for three people" and my hand shot straight in to the air. Along with me was a woman who works as a L&D nurse, and a girl who was going to be starting medical school. The three of us put on our full body scrubs - a floor-length robe that tied in the front, hair nets, and shoe covers - and giddily followed the doctor back behind the closed doors.

The room in which women labored was one large square with beds side-by-side all along every wall. In the center of this circle of women was the nurses station. You can sort of see what this looked like in the picture below, with the women in beds along the right and back wall, and the nurses station on the left. There were only two doctors for all the women laboring in the room, several nurses, and a few student doctors.

The labor room was maybe half way full on this day. The women laboring in the room were eerily quiet. The doctor says it is not always this way; if one woman starts to moan or yell, they all start. But on this day they were all labor completely silent. This seemed very interesting to me for a couple reasons: 1. Every single woman in this hospital receives pitocin. This is a public hospital that sees a lot of women every day, and they want to speed things up and get them moving along. So whether or not you are being induced or not, you receive pitocin for augmentation. 2. This hospital does not administer pain medication of any kind. You only receive an epidural if you are headed into a c-section. So all of these women were laboring in bed, on pitocin, with no pain medication, completely silent.

All these women are on IV's, some with additional medications for high blood pressure, and there are only 2 electronic fetal monitors for the entire labor and delivery floor. What this means, the doctors explained, is that these get rotated every two hours around the room. So a woman might only be on the EFM once during her entire labor. This is part good and part bad. It is slightly worrying to have women on these intense drugs and not be monitoring how the fetus is responding. On the other hand, since we know that that continuous EFM doesn't actually work any better than intermittent monitoring on detection of fetal distress, and that EFM actually increases the C-section rate without benefit to the baby, it is a blessing in disguise.

The women labor in this room until they feel the urge to push. Then they are checked, and if found to be 10 centimeters, they are wheeled into a separate room for delivery. There were 3 delivery rooms across a small hall from the labor room, with no doors in the door ways. Oh, I forgot to mention that these women are completely alone while they labor and while they deliver. No husbands, no family members, no doulas. The doctors had never heard of a doula, and I had to explain many times the way in which a doula was not a nurse, but like a nurse. All in Spanish, by the way. They said they understood, but I'm not sure that they did.

While the doctors were telling us all the information about L&D, a woman was pronounced fully dilated and was taken to one of the delivery rooms. So, we all went over, too! The doctors told us, as we watched from the doorway, that the deliveries are attended by the residents. The residents catch the baby and do the newborn assessment, with the assistance of a nurse. The attending doctors observe and advise in a hands-off manner. The woman who was having her baby was quietly and effectively pushing. She wasn't yelling or freaking out, and no one in the room was telling her when or how to push. She just pushed (on her back), and the doctors waited. In fact, no one spoke to her at all. It was myself and the L&D nurse who were saying things like "good job, mama" and then, when she had the baby "felicidades!"

The doctors explained that every woman in this hospital receives an episiotomy. Why? Because the students have to practice! After the mom had her baby, my colleague who was taking pictures asked the mom if she could take a photo of the baby (who was in the warmer on the other side of the room). The mom was crying happily over on the bed by herself, and said yes. Then my colleague showed her the picture on her digital camera. She was probably the only woman in that hospital to be able to "see" her newborn so fast, or have such an early picture! Goes to show what sorts of things we take for granted.

It was so exciting and fascinating to see what birth was like in Panama. In some ways it could be celebrated. The Cesarean section rate at this public facility was about 23% (more than the WHO recommends, but less than the United States), and that the hospital advocated for Vaginal Birth After Cesarean section (VBACs). VBAC is a contentious issue, and it’s nice to hear thatthis hospital is practicing evidence-based medicine on this topic. In the labor room, the doctor told me that they also advocate for the baby to room-in with the mother postpartum, and that they practice delayed umbilical cord clamping. These are practices that the U.S. is still working to implement in many hospitals.

In other ways, however, the labor and delivery process was quite behind. Women labored in beds side-by-side in one room without pain medication or the presence of loved-ones and received routine episiotomies. Being as this is a public hospital it is safe to say that an enormous number of Panamanian women are having their babies this way.

I am curious about why the hospital’s maternal mortality rate doubled in the last year from 40 to 80 deaths per 100,000. This wasn’t really answered, though I’m glad to hear that it is being researched. I found it interesting that in response to my question about the presence of midwives, the doctor we spoke with merely stated that they are not “necessary” here. I assume this is because they have doctors, so they believe midwives are not needed. This is interesting, because it is much further from the European model (where midwives see the majority of births, unless they are high risk) than even the United States.

I apologize for the delay in writing about my experience - it probably means I've left out some of the detail! Right after I returned home from Panama I was rushing around doing work on my thesis research and kept putting off the writing of this story. I hope you've enjoyed reading about it, anyway!

Has anyone given birth in Panama? I'd love to hear your experience! 

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