The ticking biological clock;which is the best decade?

Women should plan pregnancies when chances of conception are highest, they are in good health, and are more likely to deliver a healthy baby. The optimal biological decade for conception is between 25 to 35 years.

This optimal conception decade is dictated by the fact that women are born with a finite, genetically determined number of eggs in their ovaries. The pool of eggs is highest at birth amounting to about 2 million. However most of these eggs are destined to die, and by puberty, there are only about 500,000 left. The majority of these remaining eggs are also lost with every menstrual period, and only about 400 to 500 are potentially available for conception between puberty and menopause.

In teenage and adolescence, there is physiological immaturity of the reproductive system, hence this is not the optimal period for childbearing. There are more pregnancy associated complications in this age group. Additionally most women are unlikely to have adequate resources to care for a family.

The age of 25 – 35 years is optimal in several respects. There are more eggs available and of good quality, translating into less risk of miscarriages and birth defects. The chances of conception are higher, and remain more or less constant. This is a period of general good health; with less risk of chronic diseases. Once pregnancy occurs, it is more likely to be uncomplicated.

After the age of 35, chances of conception start to decline steeply. The body is unable to replenish the declining pool of eggs. Hence the number of potentially available eggs is much lower, and this is compounded by a decline in the quality of the eggs. Ovulation also becomes more irregular. All these factors reduce the chances of conception. By the age of 40, the chances of conception and live birth have declined by about 50% compared to 30 years of age. If conception does occur, there is a higher risk of miscarriages, birth defects and pregnancy related complications.

Careers and other priorities do not always conform to biological clocks. So what should couples do if they are not ready for a family when it’s biologically optimal? Being aware of fertility decline with age is critical. Women can always take their chances, and hope that they will conceive when ready. Fertility preservation options are available, but at great medical intervention and expense. Eggs can be removed from the ovaries and frozen for future use. Better still, such eggs can be fertilized with sperms then frozen as embryos, which have better survival. These can then be used in the future.

Male fertility mirrors the same decline as in women. Sperm numbers may remain relatively good, but the quality declines with age. Hence the same advice applies.

Kids’ health in this city

Nairobi, like most cities in developing countries, is full of kids. Latest demographic figures estimate that about 42 percent of the Kenyan population is under 14 years. Extrapolating that to the Nairobi population brings the total number of children to well over a million.

The city owes this vast number of children many things that include proper housing, clean water, food, safety and good health. Children’s health starts in the womb, Nairobi women must have access to good maternity care.

And this is more so for the lower socio-economic group, majority living in Nairobi slums and only able to access wanting public services.

Once the children are born, we must encourage breastfeeding, and if at all necessary, support mothers who must feed their newborns with formula milk. Simple advice that newborn babies should sleep on their backs and in separate cots, have been proven to save lives by preventing Sudden Infant Death Syndrome (SIDS). Support with nutrition helps prevent childhood diseases related to malnutrition. And we must ensure that every child gets the recommended vaccines.

Preventing injury and other diseases takes priority as kids grow bigger. City by-laws should enforce measures that include mandatory helmets for bicycles, car restraints and seat belts, and general road safety measures for children. Some countries report reduction of car-related childhood injuries by up to 70 percent through enforcement of seat belt use alone.

City parks must also be conducive for use by children. Physical activity is vital for growing kids, who must be encouraged to have about 60 minutes of moderately intense physical activity most days of the week. This helps with development of healthy muscles, bones and joints, in addition to limiting childhood obesity with its associated ills.

There is more to do in the home front as well to optimize childhood health. Parents and carers must inculcate healthy behaviour in kids. Simple hygiene and hand washing prevents many diarrhoea and vomiting diseases. Kids must sleep under insecticide treated mosquito nets, every night without fail. And all house hold hazardous material, including medicines must be kept out of the reach of kids all the time.

General house safety must be ensured, with smoke and gas alarms, and planned escape routes. Kids must be supported with school work and their own individual interests. We should never tire to compliment them as often as possible, this boosts their confidence and psychological morale. And let’s not expose our unhealthy habits to kids, like excessive drinking and smoking.

No matter all reasonable precautions, children will occasionally get sick or injured. Over-the-counter remedies are ill-advised, common conditions like coughs and colds hardly need antibiotics. Assessment by a Paediatrician of Family doctor is the best approach.Nairobi County must provide well-staffed and stocked health facilities catering for the city’s kids.

Futile medical care

The concept of futile medical care has been in existence for ages, but still attracts lots of controversy. It is defined as the provision of medical treatment when there is no reasonable hope of improving or curing the patient’s condition. Proponents argue for discontinuation of any treatment that hasn’t been shown to provide any measurable benefits. Stopping futile care isn’t equivalent to active intervention to end life, as withholding care doesn’t hasten the natural progression to death. By its provocative connotations, futile medical care has differing interpretations within different contexts.

Futile medical care was brought into prominence in the early 1990s by the case of Baby K in the United States of America. Baby K was already known to have severe developmental brain abnormalities incompatible with life, long before birth. The mother refused medical advice to terminate the pregnancy, eventually delivering a baby who required intensive care to sustain life. The doctors were at odds with the mother at the futility of providing continued care for a condition that couldn’t be improved or reversed. The courts got involved. Baby K lived to just over two years, leaving a reference source for arguments about the futility of the care she received during her brief lifetime.

There are plenty of other examples of futile care. Common cases involve advanced and incurable terminal cancer. Regardless of repetitive surgery, chemotherapy or radiotherapy, the end result is the same. Cases of brain-dead patients are not too uncommon. They can be sustained on life-support machines for ages, but the eventual goals of such approaches are often hazy.

But how is the decision at the futility of medical interventions arrived at? Who makes such decisions? Is it the doctors, patients, family and relatives, or the state? Arguments against providing futile care include the likelihood of harming patients, and the diversion of resources that could have been utilised in other beneficial ways. Scientific attempts at coming up with decision-aiding algorithms are already in existence. A case in point is in patients with severe burns, and those unresponsive to prolonged resuscitation following cardiac arrests. If the prediction is the inevitable progression to death, the futility of further efforts wins the argument.

As medical advances continue to improve, questions of futility will continue to raise debate. The arguments aren’t just scientific. There are issues about ethics, religion, beliefs and social-cultural expectations. There’s even been an argument about making futile care a market commodity, not unlike the purchase of luxury goods and lifestyles. If the purchaser can afford futile care, regardless of how much it costs or it’s benefits, they can as well have it. The caveat should be to ensure equitable access of similar care to other patients with treatable conditions.

The will to live appears to be very strong even in situations deemed hopeless by clinicians. This can never be ignored, and will remain the main driver for futile medical care.

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

You don’t have to exercise daily to remain healthy

The health benefits of maintaining regular exercises are far and wide. When you remain physically active, you reduce your risks of chronic diseases like diabetes and cancer. Risks of heart disease come down as well, and life expectancy tends to be longer. But the question has always lingered about how much one needs to exercise to reap adequate health benefits.

The general recommendation for adults is 150 minutes of moderate physical activity, or 75 minutes of vigorous exercise per week. This doesn’t appear to be a huge amount of time to dedicate each week to physical exercises. But a typical working week has so many other competing interests, and dedicating time daily to exercises may not always be possible. So could you cram your exercise hours to one or two days per week and still reap the health benefits?

Some researchers in northern Europe have tried to address this very question. They looked at data on individuals who exercised only once or twice in a week, and compared health parameters with those exercising most days of the week. The results showed that those exercising less days in the week had almost similar health benefits to their counterparts who exercised almost daily. The data supports the idea that some physical activity, even below recommended thresholds, helps prevent disease and premature death.

How does this relate with your physical activity regime? If your schedule allows for daily exercises, keep at it. On the other hand, you don’t need to feel guilty when you miss out on several days of exercises in any given week. Well, try and catch up on the weekends, or any other time that you can spare. You can choose to cram all your weekly exercise hours together in one or two bouts. And you will still remain on the brighter side of health.

But while frequency of exercises may not be too important, you cannot put your guard down and get away without any exercises at all. Doing some sort of physical activities every so often, even when this is below the recommended thresholds, still confers health benefits. If you can’t manage a vigorous aerobic workout, you could at least do a brisk walk. Or a light jog, or a swim, or any other activities that may take your fancy. The idea is to make sure you are not sitting around all the time, get up and do something.

Remember physical exercises are just one component of all the things you should be doing to maintain good health. You must also eat healthier, drink less, avoid smoking, and be up to date with all your health screening. Knowing you can skip some days off your exercise schedule is no excuse for engaging in other unhealthy activities.

If you are considering a home birth…

Dear doctor, am slowly approaching the end of my first pregnancy. Am considering a home birth, is this a viable option for me?

Home births were the norm in aeons gone by. But by the turn of the 1900s, hospital births started becoming more common. It is estimated that nowadays, home births account for only one percent of all deliveries. However some developed countries have well-organized programs that support home births, recording slightly higher regional statistics.

There are several reasons why some women are attracted to the possibility of delivering at home. For starters, you deliver in familiar surroundings, and have a chance to share the experience with family and friends. Some want to avoid the medicalization of labor and delivery, which is inevitably associated with hospital births. Still others may think of the costs associated with hospital deliveries. Some studies estimate that home births can be up to 60% cheaper compared to hospital births.

Whatever your reasons for considering a home birth, there are several factors to consider. Your pregnancy must be considered low risk and uncomplicated. You must discuss the plan for home delivery with your midwife and obstetrician well in advance. You also need to identify the team that will supervise your home delivery. Such a team would ideally include two midwives, with an obstetrician readily available in case their presence is required. It’s also prudent to identify a paediatrician who should be on standby.

A plan B is also required in case things don’t turn out very well. You see, the process of labor is dynamic and unpredictable. Unforeseeable eventualities may happen, necessitating abandoning the previously well-laid plans for a home birth. Labor involves progressive uterine contractions, continued opening of the cervix, and ongoing descent of the baby into the birth canal. Sometimes these coordinated events may not progress optimally. Your baby may also go into distress, creating an emergency situation. All sorts of other labor -related complications may occur. Thus your plan B must be clear about how to respond to any emergencies that may arise, including rapid transfer to the hospital.

There is an inevitable debate about the safety of home deliveries. You will come across several scientific studies about the subject, and heated exchanges among professionals about the merits and demerits of home deliveries. It appears home births are associated with a slightly increased risk for the unborn baby, and even the mother as well. But it’s clear that carefully selected low risk women can safely delivery at home, so long as all precautions are put in place to take care of any eventualities.

Go ahead and review your plans for a home birth. Make sure you understand the complexities involved, and take care of even the minutest of details especially as relates to safety. If any doubts arise, delivering in hospital remains the safest option.

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