Early detection of birth defects – a far cry
This is the moment in history when Bangladeshi medical science marked a milestone by successfully completing the remarkable surgery separating the ten-month-old pygopagus twins Tofa and Tahura. Twenty-four doctors spent nine hours inside an operating theatre operating on the spine of the twins.
This is also the time period when only 30 percent of mothers completed all four antenatal care hospital visits. The four basic hospital visits that are needed to gauge the viability of a pregnancy against potential health risks to mother and child. In an interview with The Daily Observer, their pediatric surgeon Dr Shahnoor Islam said that Tofa-Tahura's mother has never had any ultrasound or test.
As a result the twins were delivered at their nanabari, their maternal grandparent's village home in Gaibandha, under the supervision of a village midwife. It is a miracle itself that their mother survived such a complicated labour. According to data by Every Preemie-SCALE, a USAID multi-country project, last year when these babies were born, 48 percent of all births were unattended home births.
Praise for the brilliant doctors at Dhaka Medical College Hospital's Burn and Plastic Surgery Unit who managed this laudable feat should also come with the acknowledgement that Tofa-Tahura's mother had no idea she was having conjoined twins because she falls out of reach of formal prenatal care.
The same can be said of the toddler Choity Khatun, the girl with three legs who returned home last year after a successful surgery in Australia funded by Children First Foundation. If it was only a third limb that needed to be separated, it would not have been such a tricky situation for the three-year-old. She had caudal duplication syndrome where her body absorbed her twin's in the womb, leaving Choity with double organs, and in irregular places. The mother never sought antenatal care.
Just last year DMCH saw two more cases of conjoined twins. One of the cases was a pair of newborns sharing legs but with two heads, who were abandoned at the hospital to die. The other case hailed from Zibannagar upazila in Chuadanga, where a mother gave birth to two babies joined at the chest. In this case, the ultrasound was only done right before delivery.
It is important to ask why these women fell outside the radar of institutional prenatal care.
Late last summer when the waters in the north of the country were on the rise, Moushumi Akhter was living marooned in an island village in a haor. She and her neighbours have to wait for up to two hours for a boat to the shores of the mainland. From there the hospital is approximately another 12km away. A hospital visit is costly, requires a family effort, and is worth a day's wages. Moushumi is in her late teens now, but was 15 years old only when pregnant with her first child.
"I would not have gone to the hospital for a check-up during my pregnancy but I slipped on the mud and fell into the water. My family members were afraid that I might miscarry, so they took me to the mainland," said Moushumi. She delivered her son at home afterwards, and even had another one after that at home. Why had she not gone to a hospital for prenatal care, or at least for the delivery, I asked her. Because none of the other women told her to, Moushumi said, shrugging off the question. The mother had dropped out of high school after her wedding because she could not afford to take a boat to school anymore. Taking a boat to the mainland is a big deal for this woman who lives hand-to-mouth.
Putting it into context, the answer to why Moushumi had not received formal prenatal care is multi-pronged. To begin with, she is too far away from the nearest hospital or health complex, and too impoverished to afford the trip. Add to that the fact that a pregnant teenager would require somebody to take a day off work and accompany her. All of this is assuming her support network thinks it is necessary for her to go to the hospital; in this case, since she had left school, her only support network is her family.
This is not in any way unusual. Several years ago, I spent summer of freshman year asking the mothers of Raozan upazila in Chittagong why they did not go to the hospital for prenatal care. Across all age groups—from new teenage mothers to middle-aged matriarchs—they had one reason: their family did not think it was necessary. The only factor that seemed to make a dent in this reasoning is if the mother was educated.
A University of Rajshahi team did a nationwide survey that got published in PLOS journal last year and found that "women who were married after age 18, had secondary or higher level of education, and were from the wealthiest households were more likely to utilise antenatal and delivery care".
In retrospect, perhaps the entire discussion is doomed to be Sisyphean in nature without equity in health care and policy changes that let women be in charge of their bodies. As Tofa and Tahura go off to lead a happy, normal life, two more girls are queued up to be separated. Rabia and Rukia were brought to Dhaka from Pabna in July and are joined at the head; doctors are now assessing the situation to see if a surgery to separate them will leave them with brain damage.
Here however is the catch: in an interview given to the British newspaper Daily Mail, the twins' mother said that she had gone for late-stage prenatal care. After assessing her ultrasound, taken during the last month of her pregnancy, her doctor told her that the heads of the fetuses were too large, and that it was probably due to fluid accumulation. The doctor prescribed anti-inflammatory medicines. The fact that an upazila level doctor could not identify conjoined fetuses days before labour is distressing. Conjoined twins can be detected as early as the beginning of the second trimester.
Having said all of this, if a mother does find out that she is carrying conjoined twins—which in all likelihood will not be before her second trimester—scoring a termination will be a legal and moral dilemma. And so, we make a full circle back to where we started.
Zyma Islam is a member of Star Weekend magazine, The Daily Star