Balancing quality and cost of women’s health care

The quality of health care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes, and are consistent with prevailing professional knowledge. It must be the right care, for the right person or population, at the right time. The quality of women’s health care in Kenya varies greatly among various providers: public institutions, private sector, non-profits, faith-based organizations and private practitioners.

Quality and cost of care are intricately related. Access to medical insurance, or self-funding dictates where women seek services. The lower income group have limited choices. Public health institutions have poor infrastructure and limited resources in personnel, equipment and supplies. This is in addition to bureaucratic governance hurdles, with direct consequences in the quality of service provided. Investments in public institutions can easily turn around dilapidated facilities into world class status, and make them the first choice for many. High quality of care in public facilities is the single most contributing factor to lowering maternal deaths in Kenya.

Private health facilities operate in a ‘business mode’, seeking a balance between service provision and profit. They are better equipped, have clear governance structures and strive to be better than competitors, including the public sector. Women must pay hefty charges to access such facilities, either directly or through insurance. But is the care necessarily better? There is no doubt that infrastructure and other resources in private facilities are better. There is a lower risk of dying. But there is a higher risk of unnecessary interventions, at best causing no harm but at worst leading to disability and in rare cases death. Any unnecessary intervention impacts on the cost of health care and insurance, thus further reducing the number of women who can access such services. Strict guidelines and adherence to medical ethics can mitigate against practice more bent towards profit rather than quality.

Faith-based facilities and non-profits have different modes of funding, taking a middle place between public and private facilities in terms of cost. They are more accessible to the wider population, stretching their services to the limit due to sheer numbers. Stretched services may inadvertently impact on quality.

Private office consultation is satisfying in lots of ways, but has its drawbacks. There is no solo Gynecologist capable of having specialised expertise in all areas of Gynecology. Cross-consultation with other specialists or group practice should be the norm, otherwise quality of care deteriorates with biased opinions. The most expensive may not necessarily provide the best of care.

Balancing cost and quality of care must be a deliberate effort for all providers. Every woman must be able to access care that is efficient, effective, acceptable, equitable and safe. This is the only way to improve our dreadful women’s health statistics.

Optimal antenatal care and delivery

Every pregnant woman should have antenatal care (ANC) under the supervision of a skilled health worker, and in a well-equipped facility. Skilled ANC providers include Midwives and Obstetricians, often working together as a team.

Ideally, care should begin pre-conceptually. This is an opportunity to review issues that may adversely affect the pregnancy, and take remedial measures. Pre-conceptual Folic Acid should be commenced and continued until 12 weeks of the pregnancy.

All women should make efforts to commence ANC at about 12 weeks of pregnancy. A full medical evaluation is done, and routine screening tests are requested. The tests include screening for HIV and Hepatitis, Syphilis, urine checks, blood group and level of haemoglobin. An ultrasound scan is also done, confirming the duration of the pregnancy and giving an estimated date of delivery. This scan also provides an opportunity to screen for some fetal abnormalities. Additional tests may be offered depending on specific circumstances.

Education and counselling are integral components of this first visit. Couples are advised on danger signs, educated on healthy habits and preventive measures for certain illnesses like malaria. Individual medical profiles guide nutritional supplements, immunisations and preventive medications. An ANC card is then offered, and each couple should keep a copy of this. If the 12 week visit is skipped, opportunities are missed to optimise and plan subsequent care.

Screening for chromosomal abnormalities such as Downs Syndrome is not universally available, and is expensive. Couples must make the choice about having such tests, as they must contend with implications of positive results. A detailed ultrasound scan should be offered at around 18 – 22 weeks, aiming to exclude fetal developmental defects. Detailed scans are not universally available as well, and should only be done by specially trained caregivers.

Subsequent ANC visits must be individualised to be cost-effective. The WHO recommends further visits at 20 – 24 weeks, 28 – 32 weeks and at 36 weeks. At each of these visits, maternal health must be re-assessed and fetal growth monitored. If complications such as raised blood pressure (pre-eclampsia) or poor fetal growth are detected, specific measures must be put in place. These may include more frequent ANC visits, fetal growth scans, and specific decisions on the timing and mode of delivery.

Birth plans should be made and agreed during the antenatal period. This includes selecting the facility, desired birth positions, pain relief, birth partner etc. It is worthwhile making a pre-delivery visit to the chosen facility to get familiarised with the layout and the staff.

Every delivery should be supervised by a skilled birth attendant. This must be in facilities well equipped to handle complications of delivery, or capable of timely referral to more equipped facilities. Putting such measures in place dramatically decreases the number of women suffering serious complications or dying during pregnancy and labor.

Revealed: Frequently asked Gynecology questions by men

Men don’t routinely visit Gynecologists . But some harbor anxieties when their female partners attend for Gynecological consultations. Over the years, I have had multitudes of questions from men, some anonymously and others in person. For those not bold enough to seek answers in person, here’s a glimpse of what many may have always wanted to know.

Are internal examinations done every time women visit their Gynecologists?

The answer is no.Internal examinations should only be done for very good reasons, and not on a whim. All intimate examinations should be done in the presence of a chaperone to negate any potential misdemeanors in either party. If a chaperone is not offered, or if declined, appropriate documentation must be made.

Can an abnormal Pap smear affect the male sexual partner?

Minor changes on the cervix are fairly common, and either resolve spontaneously or require specific treatment. There are no untoward effects on men, but psychological effects in either or both partners may interfere with intimacy.

Fertility

Fertility problems are fairly common, and there is a biased belief that the problem is usually with the women. Surely, men can’t have any fertility problems?Far from the truth, men are the cause of fertility problems in about a third of all cases. The surest way is for men to accompany their partners to a joint consultation and get basic tests done, thereby resting the matter.

Does pregnancy mandate sexual abstention?

The general answer is no. Sexual intercourse in pregnancy is generally safe. There are only a handful of pregnancy complications where abstention may be advised, for example if waters rupture prematurely or in certain cases of heavy bleeding in pregnancy. Adjustments may be necessary to accommodate pregnancy changes that may interfere with certain positions, or the female partner’s desires.

What about after delivery?

A common concern with men is that pregnancy and delivery causes irreversible bodily changes, and that pre-pregnancy levels of intimacy and enjoyment are no longer achievable. Pre-pregnancy physique can be achieved with physical exercise and healthy diet.Instead of whingeing, men can play an active role in helping their partners get back to desirable physiques.

Some men want to know why there are so many male Gynecologists, and if male Gynecologists are somehow wacky.

Male predominance has been by default, and the vast majority are not wacky. There is now a reversal of trends where the majority of graduating Gynecologists are women. If any couple are only comfortable with a female Gynecologist, such a choice must always be respected and facilitated.

Occasionally, a man comes along and wants to know details of his wife’s consultation.

The answer must always be no. The medical law is unambiguous on confidentiality. Husbands have no legal right to their spouse’s medical information, Gynecologists can only divulge such information with written consent of the woman concerned.

When a medical relationship breaks down

It is more than likely that you have a regular healthcare provider. It may be a health facility that you frequently patronize, or a general practitioner that you see every so often. Or even a specialist whom you have tended to see for specific health problems. Whatever the case, many years of being cared for by the same healthcare provider inevitably leads to some sort of professional relationship. Either party feels at ease with each other, positively impacting on ongoing medical interactions.

But even well-rooted professional relationships can falter. This can be due to a variety of reasons, either initiated by yourself, or by your doctor. Let’s start with you. Over a period of time, you may start getting dissatisfied with the kind of service you are getting. It may be simple things like long waiting times to see your doctor, or unavailability of suitable appointments. More seriously, you may start distrusting your doctor’s competence, sensing an ever increasing need to seek further opinions elsewhere. Whatever it is that comes up, you may get to a turning point, mandating delinking yourself from a longstanding medical affair.

Your doctor too may get to a point where they are no longer interested in your custom. They may be getting too busy, and looking to filter out some patients from their practice. They may find you unwanted for other seemingly simple reasons. May be you are too demanding, or a hypochondriac who annoyingly keeps consulting for mundane reasons. Or your doctor may just be transiting into a more specialized practice, meaning that you’d be better off seeing somebody else. Well, your doctor too is at liberty of severing your longstanding relationship.

Whatever the reasons for the breakdown of a medical relationship, you must be ready to move on. You could try to work things out with your doctor. Bring up any issues arising from your end, and see whether a common ground can be found to restore the relationship. Mending an icy relationship that appears to have been initiated by your healthcare provider can be trickier. It’s however more likely that you end up with a formal communication explaining your available options. You see, medical ethics mandate doctors to facilitate ongoing care, if they are unable to provide such care themselves.

Moving on shouldn’t be too much of a problem when a longstanding medical relationship comes to an end. All you need is to shop around for alternate healthcare providers. Take your time and come up with a checklist of things that really matter to you, especially if you had negative experiences from your previous doctors. Who knows, getting yourself a new doctor may be a fresher health perspective, leading you into better health ideals. Well, until this new relationship gets to its inevitable end, which it must, as with all kinds of relationships.

Dr Alfred Murage is a Consultant Gynecologist and Fertility Specialist. amurage@mygyno.co.ke

E-cigarettes are fraught with harmful effects

There has been an explosion of many versions of e-cigarettes in the last few years. This has been a veiled attempt to mitigate the already known risks of smoking traditional cigarettes. But e-cigarettes are trendy, and have becoming increasingly attractive not only to smokers trying to quit, but to newer and younger smokers. Over time, there’s ongoing realization that e-cigarettes may not actually be a safer alternative.

But what actually are e-cigarettes? They are handheld battery powered vaporizers that simulate the action of smoking, without actually burning tobacco as in traditional cigarettes. A liquid solution is heated up to a vapor, which the user inhales, hence the term vaping. The liquid solution may have many ingredients that include nicotine, flavors and other additives. E-cigarettes have become big business, with estimates of about 500 brands, and global sales upwards of 7 billion USD.

E-cigarettes are generally thought to be safer than combusted tobacco products, with their lower health risks being compared to smokeless tobacco. They have also been credited with helping smokers to quit the habit, and reducing the overall tobacco related health risks that include cardiovascular disease and cancers. Nevertheless, there are ongoing concerns about the ingredients contained within the e-cigarette liquids. The inhaled vapor may contain potentially harmful chemicals, toxicants, carcinogens and even heavy metal particles that can cause disease.

There are indeed ongoing reports of severe lung problems resulting from vaping. It appears the inhaled vapors can cause harmful changes within small blood vessels in the lungs, leading to cumulative lung damage. It doesn’t stop there, damage to blood vessels in other organs like the heart and brain will subsequently lead to cardiovascular and neurological disease. Continued vaping, especially with brands containing nicotine, risks the danger of addiction and longterm health risks. There have also been the odd reports of some e-cigarettes exploding whilst charging or in use. Some have suffered severe burns and other injuries, necessitating corrective surgery.

So what’s the way out for those attracted to vaping? Well, if you have never smoked, don’t be swayed by the e-cigarette trend. It may look fancy and recreational, but it may end up being the wrong health path for you. For those trying to quit from traditional cigarettes, vaping may reduce the toxic effects accruing from combusted tobacco. But it isn’t a harmless substitute. Never forget that even without nicotine, e-cigarettes are still harmful. Other forms of nicotine replacement and quitting aides may be healthier alternatives. In the long run, you are better off quitting completely. No traditional cigarettes, no vaping, no nothing.

Some authorities have re-emphasized the obvious: there is never any need to inhale anything else except air! The only exceptions are certain medications, like the inhalers commonly used by asthmatics.

Dr Alfred Murage is a Consultant Gynecologist and Fertility Specialist. amurage@mygyno.co.ke