Sunday, June 25, 2006

Prenatal Care in Southwest Alaska

The Yukon-Kuskokwim Delta is a huge region that presents some unique challenges when it comes to providing prenatal care. Distance and weather are significant barriers to care when the need is urgent. Many villages are more than an hour’s flight to the hospital in Bethel when the weather is good; when the weather closes down, due to fog, wind, snow storms, or severe cold, a pregnant woman may be many hours or even days from the care she needs.

Routine prenatal care is provided at the hospital by family practice physicians, physician assistants, nurse practitioners, and certified nurse midwives. We have one OB/gyn specialist on staff who oversees the high risk pregnancies and coordinates care with the perinatologist in Anchorage for the very high risk patients.

There are about 400 births per year in our hospital; most are uncomplicated vaginal deliveries that require very little medical intervention. We have two nurse anesthetists, but no anesthesiologist; we don’t give spinal anesthesia for deliveries. Our rate of Cesarean section is fairly low; we do perhaps a dozen C-sections per year. Three of our 15 family practice physicians, and the obstetrician, have privileges for C-section.

Patients are designated as having a high-risk pregnancy for a number of indications, most commonly grand multiparity—more than five previous deliveries. Risk of hemorrhage at delivery increases significantly for a grand multip, and many of our moms have had more than nine or ten children. Some have had more than twelve, and a few have had more than fifteen. There is strong cultural support among the Yupik Eskimos for early and frequent childbearing. Most primips (first pregnancy) are teenagers, and many grand multips are women in their forties (advanced maternal age). We also have a fairly high rate of pregnancy-induced hypertension and gestational diabetes, as well as chronic hypertensives and diabetics who become pregnant. We have a small, but slowly-growing population of HIV positive patients in the Delta, and some of those become pregnant as well.

Genetic diseases are an area of concern for our obstetrician also. Congenital adrenal hyperplasia—known more commonly here as AGS, for adreno-genital syndrome—is frequently seen in the Delta, and many families have more than one AGS child. There is a much more rare condition known as Kuskokwim Syndrome which occasionally occurs. These patients are born with permanent hip flexion contractures which can vary from mild to severe; some will never walk at all, and the milder cases will only walk with a very hunched posture.

Most women in the Delta will present to their village health aide for a pregnancy test within two weeks of missing a menstrual period. Once a woman has a positive test, she will qualify for Medicaid and WIC, and the health aide will file that paperwork for her. The Encounter Form from that visit is faxed to the hospital as Radio Medical Traffic and she is enrolled in the Prenatal Program. She is started on daily prenatal vitamins, calcium and iron supplementation, and is scheduled in the Family Medicine clinic for a first prenatal visit (about an hour), and in Radiology for a dating ultrasound, at 8 to 10 weeks gestation. There is an extremely low rate of pregnancy termination here; undesired pregnancies are far more frequently carried to term and the infant adopted out: to the pregnant patient’s own parents, or her extended family, or to an unrelated family in another village. Infants are almost never adopted outside the culture. If a termination is desired, the patient is referred to a provider in Anchorage, or occasionally in Seattle. Elective terminations are not performed at our hospital.

After the first prenatal visit in Bethel, a woman with a normal pregnancy will remain in her village and have monthly prenatal visits with the health aides. Health aides are trained extensively in prenatal care and follow their pregnant patients closely. They know who is drinking or taking drugs, who is experiencing domestic violence, who is not taking supplements or eating well, and who is having too much morning sickness. They report their concerns to their village provider and arrange for counseling, or evacuation to the women’s shelter in Bethel, or Vitamin B supplementation. At any one time, there may be as many as a dozen pregnant women in any one village.

All pregnant women spend their last month of pregnancy in Bethel. At the first prenatal visit they are given their “Be in Bethel” date—the beginning of the 36th week. Women from the village refer to this as “going to wait” and they generally hate it. It is very difficult for them to separate from their families and their village for such a long time. They sign a paper at their first prenatal visit acknowledging their Be in Bethel date, and their understanding of the repercussions if they stay in the village past that date: that they are placing an unfair burden on the health aides of the village, and that they may be placing their own lives and the lives of their unborn children at risk by doing so. If necessary, attempts to medevac will be made, but if weather is prohibitive, the lives of the medevac team will not be risked to bring them in.

Most women do come in, on or near their Be in Bethel date. If they have family or friends in town to live with for that month, they may do so. If not, they spend the month living at the Prematernal Home. The home provides dormitory-style living for about 30 women. They are assigned a room shared with one roommate, and have regular chores to do, mostly cooking and clean-up. Partners/husbands, family members or friends may come to town to visit them, but are not allowed to stay at Prematernal Home.

The women have weekly prenatal visits (twice weekly for high-risk patients) at the hospital during their last month. Prematernal Home is just less than a mile from the hospital, and most of the women walk back and forth for the exercise, which is strongly encouraged. They may go ice fishing in the winter, or berry picking in the summer; but most are pretty bored, especially if there is no one else from their village also waiting. They are often homesick or worried about their children back home being cared for by relatives. It is a difficult time for them, and the temptation to make a quick trip back just to check on things is strong, especially for the women from nearby villages.

Despite this well-established system, village deliveries do occur about ten to twenty times per year. Most of them are premature, occurring before the 36-week Be in Bethel date; but a few are full term infants born to stubborn moms who refuse to come in, or who fly back home for a weekend. The health aides do a magnificent job in these situations. Health aides in one of my assigned villages last year delivered a double footling breech successfully, with no help except a doctor in Bethel talking them through it on the phone. That baby is now a healthy toddler known to all as “Footy.”

When a woman in the village goes into labor before 36 weeks, a big medevac ensues. The health aides get her to the village clinic by any means available (hand-carried reclining litter or dogsled pulled by four-wheeler or snowmachine), place a Hep-lock for IV fluids, and get a phone link established with the ER physician in Bethel. They have terbutaline in the village, which they can give on the order of the physician, to try to slow her contractions. Meanwhile, the on-call family practice physician and pediatrician at the hospital are paged STAT to the ambulance bay for a fast ride to the airport. The flight team (1 pilot, 1 paramedic) starts warming the plane as soon as they get the call, and take off the minute the docs jump on board. The near villages—Kwethluk, Napakiak, Akiachuk—are only a fifteen minute flight; the distant villages—Kotlik, Scammon Bay, Tununuk—take over an hour to get to. That’s in good weather with good visibility, and it often isn’t. Most of the villages now have lighted airstrips, but not all. In December we only have four to five hours of daylight, so it is a major concern. If necessary, the health aides will get on the VHF radio and ask everyone in the village with a snowmachine or four-wheeler to drive to the airstrip and line up on each side with their headlights on. Whatever it takes.

Hopefully, the team will arrive before the baby delivers. If not, it is all up to the health aides. There are no incubators in the village clinics, so they put a space heater in the smallest exam room and try to get the temperature up to 100 degrees; and they warm up bags of IV fluid in the microwave to lay next to the infant. The team brings an incubator with them for transporting the infant back to Bethel. A medevac team from Anchorage may meet them at the Bethel airport for a tarmac transfer if it is necessary to get the infant to intensive care. Our hospital has no intensive care unit at all.

More often than not, these heroic efforts end well. Dedicated staff overcome huge challenges of geography and climate to deliver state-of-the-art medical care to the people of this region. It is not easy, but it is incredibly fulfilling, and it is always appreciated.



Blogger It's me, T.J. said...

What an interesting life you live.

And what an important job you have.

Thanks for sharing.


Tuesday, June 27, 2006 5:25:00 PM  
Blogger Navelgazing Midwife said...

This is a delightful look into care far from epidurals and cesareans on-demand.

My mind jumps to ideas regarding the women being less bored during their waiting time in Bethel. Do they not have the Internet at the home? Perhaps they could learn to knit/crochet - something they might not otherwise have time to do in their own villages.

I just know that girls in homes from unwed mothers (yes, they are still called that) complain of major boredom, too. Doulas or La Leche League leaders come in to do support groups - maybe a therapist who just wants to offer an understanding ear could lead some groups.

So many questions... do the women bond with each other? Or are there village differences similar to cultural/racial ones we all know about.

Are there women who want homebirths but just don't because of the distance to help or peer pressure to conform?

Do the women nurse their babies? How do they have so many babies so close to each other if they do. Is their body fat content high?

Thanks so much for this glimpse. Very intriguing and great for me to know and share with others.

Wednesday, June 28, 2006 6:31:00 PM  
Blogger wolfbaby said...

Wow,,, it sounds like an amazing community.. sorry haven't been by much ... I had a final that kept me a bit busy.

Wednesday, June 28, 2006 10:11:00 PM  
Anonymous Anonymous said...

Tundra PA,

I spent the last few months before PA school working in a NICU. Your description of prenatal and emergency perinatal care makes me grateful for all of the advantages we had. My hat is off to all of you who perform so well in conditions that the rest of us find so difficult.

Evan, PA-S

By the way, school is going well!

Friday, June 30, 2006 6:54:00 AM  
Blogger TheTundraPA said...

navelgazing midwife--thanks for your long and thoughtful comment. I will try to answer your questions. The women come to Bethel for their last month of pregnancy because at the public health level, it is the best way to use our limited resources to deliver prenatal care in a huge geographic area with only small planes for transportation and lots of bad flying weather. They would almost all rather stay home in their villages and deliver at home. Probably a lot of them would do just fine doing that. But a lot of them would have problems that the health aides could not address. Our rate of grand multiparity is huge, and postpartum hemorrhage is quite common. Yupik Eskimo babies are routinely over 8 pounds at birth and many are over 10; vaginal/perineal lacerations are also common, 3rd and 4th degree not infrequent. Our health care delivery system could not handle 400 births a year in 58 different villages spread out over an area the size of the state of Oregon.

Regarding Prematernal Home. No, there is no internet available to the women. Most wouldn't use it if it were; this is a culture based on oral tradition, reading and writing are not the activities most of the people use to pass their time. Most villages have internet at the village clinic, the school, and the village council office; very few have it (or want it) in their homes.

Prematernal Home has lots of craft materials available, and some of the women spend their time crafting. Crocheting and beading are popular. The women teach each other; there is no organized teaching. Some of the supplies, like yarn, must be purchased, and many of the women have no money at all.

Women from the same village tend to stick together at Prematernal. Some villages have traditionally been rivals, and women from those villages will express that attitude towards each other. Other villages have traditionally had close ties, and those women will befriend each other easily. But women from the same village can have problems too; if my grandfather hated your grandfather because of some real or imagined slight, then I can't be friends with you because that would be disloyal to my grandfather's memory. So as to bonding, yes and no. It does happen, and some women make new friends at Prematernal that they keep up with for years.

There are a few class sessions offered at Prematernal, usually on childbirth/child care topics, which the women are encouraged but not required to attend. These are dependant on volunteers from the community. We have no La Leche League, no Lamaze teachers, no Doulas; and very few mental health workers who are not already mashed flat by the overwhelming daily work load. The resources here are already stretched pretty thin.

Most women do nurse their infants. We strongly encourage it. Many only nurse for a month or so and then switch to formula (which is free). Some nurse for 6 months or more and some for years. The oldest child I have seen still nursing! Many moms are nursing a 3 month old and a 2 year old at the same time. Yes, body fat content is high. The Yupik Eskimo genetic tendency is short and stout. Recurrent pregnancy is no problem; I have seen women already pregnant when they come for the 6-week postpartum exam.

Whew! enough... I hope this has answered your questions. Let me know if you have more...

Friday, June 30, 2006 8:00:00 AM  
Anonymous stacy said...

Absolutely fascinating. Thanks for this post and the comment following.. This is my first visit to your blog but I will definitely stay around for a while and read!
PS - How could I submit a post to Grand Rounds? Will you email me if you have the time? - I have several questions.. Thanks so much! :) :)

Friday, July 07, 2006 7:50:00 PM  

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