When birth and death come face to face

Costa Rica should remember the year 2015 with joy. That year, the country reported its lowest infant mortality of the decade. For every 1,000 births, 7.74 infants under the age of one, died. What’s more, this number falls within the range expected in developed countries for that indicator: fewer than 10 deaths per 1,000 births.

I remember that year with great pain, because my first-born was part of those statistics. His name was Martín. The day he was born, the day he died, was a holiday in Costa Rica that I used to celebrate with fervor. Even though time has passed, I have never been able to enjoy it again.

When I went through the difficult process of grieving my son, my therapist told me that the death of a child or a woman related to pregnancy, the other side of this coin, combines the two great mysteries of life: being born, and dying. But really, maternal and infant mortality represent more important things than simply facing the inexplicable. They speak to us of inequity.

“The Maternal Mortality Ratio (…) is a marker to identify and put in evidence the health conditions of a country,” said Olga Araya, Coordinator of the Demographic Statistics Unit of the Institute of Statistics and Census (INEC), in November 2020, when the institute presented the latest statistical analyzes on maternal and infant mortality for the year 2019. However, delving into this topic reveals something beyond general health conditions: it also touches issues of women’s rights.

“In [the matter of] public health, a country with a good health system should have zero maternal mortality. “Any maternal death is a preventable death,” said Dr. Gabriela Arguedas, Coordinator of the Reproductive Rights Observatory at the University of Costa Rica. “In a country with an adequate health system, cases of maternal death are due to a type of institutional failure.”

For a country that prides itself on the coverage and quality of its health care, a statement like this is shocking. However, it is born out by analyses of the epidemiological transition of maternal mortality and infant mortality in the world.

Costa Rica has one of the lowest maternal mortality rates in Latin America, outdone only by Chile and Uruguay. Its infant mortality rates are comparable to those of developed countries. But the vast majority of women and a high percentage of babies who are dying in Costa Rica do so because of preventable causes.

In 2019, 13 women died from causes directly related to their pregnancies. When these deaths are translated into the statistical ratios established by the World Health Organization (WHO), Costa Rica has a maternal mortality ratio of 20.2 deaths per 100,000 births.

This rate puts Costa Rica in phase IV for obstetric transition, within the five levels established by the WHO for care and prevention of the world’s epidemic of maternal deaths. Reaching stage V would imply that all preventable maternal deaths have been prevented. In that case, Costa Rica would suffer fewer than five of these human losses per year for every 100,000 births.

Can this be done?

What would have to change in Costa Rica for this landmark to be reached?

How would the living conditions of Costa Rican women have to change before, during and after their time in the nation’s delivery rooms, so that fewer than five maternal deaths per year occur in Costa Rica for every 100,000 births?

Photographs during my pregnancy with Martin by photographer and artist Pamela Fuster. Courtesy/El Colectivo 506

Maternal mortality in Costa Rica

When a woman dies while pregnant, during childbirth or in the 42 days after delivery, and the cause of her death is directly related to the pregnancy or because her pregnancy exacerbated another health condition, her death is called maternal death.

In 2014, the Ministry of Public Health and the INEC reported that 80% of maternal deaths in the country were preventable. In 2004, the Health Ministry spokesman for this topic described 85% of these deaths as preventable. The statistics for 2019 on preventable deaths have not yet been made public, but the variable seems not to have changed much in recent years.

In Costa Rica, the maternal mortality indicator has fluctuated very irregularly since 2000. For example, 2018 saw the lowest number of deaths, with 11 deaths, while in 2000 and 2006, 28 women died.

In 2019, ten of the 13 women who fit this category died from direct obstetric causes. The history of maternal mortality in Costa Rica shows that direct obstetric deaths have been the main cause of maternal mortality. The WHO defines these deaths as “those resulting from obstetric complications of pregnancy (pregnancy, childbirth and postpartum), from interventions, omissions, incorrect treatment, or from a chain of events originating from any of the aforementioned circumstances.” In other words, women who die from direct obstetric causes are healthy.

According to the WHO, when a country reaches stage V, where all preventable maternal deaths are prevented, the causes of these deaths are indirect obstetric. This means that the women die from diseases or pre-existing conditions that were aggravated by pregnancy, or other factors beyond the control of the medical system.

For Dr. María Carranza Maxera, a researcher at the Costa Rican Institute for Research and Teaching in Nutrition and Health (INCIENSA), Costa Rica must focus on understanding the reasons why women are dying from direct obstetric causes—then work to solve those issues. “The number of maternal deaths in the country is so low that we should know each case by heart, to learn what happened and to prevent it from happening again.”

According to Dr. Arguedas, ensuring that these deaths decrease “is as simple as the medical consultation being a serious one. Listening to the patient. Giving credit to what she is feeling.” Costa Rica’s health system guarantees care for any pregnant woman, regardless of whether she is insured, her immigration status, or her age. However, Dr. Arguedas says she thinks the quality of that care is not always adequate. “The management commitments of the CCSS are becoming almost like a dogma, and in order to save money, the quality of service is suffering,” she said.

For Dr. Carranza, prenatal care is important to educate and detect established complications that could cause death, but it is also important that women have quick access to care during an emergency. It is also essential that these emergency medical teams are properly trained and have the necessary supplies.

In 2019, 40% of direct obstetric deaths were due to complications from HELLP syndrome, which is related to gestational hypertension (pre-eclampsia and eclampsia). The origin of this type of pregnancy complication is unknown, and it cannot be prevented, but it can be treated if it is detected early. The same is true for other emergencies that occur in labor and delivery.

“Even in an obstetric emergency, if the entire institutional apparatus is functioning correctly, maternal mortality should not occur,” said Dr. Arguedas.

Infant mortality in Costa Rica

In October 2015, after the death of my son, I attended an event organized by an NGO called Legacy of Angels. That day, dozens of families released biodegradable balloons with seeds inside in honor of all the babies who did not get to live. I felt the warmth of other families experiencing the same pain.

The maternal mortality ratio speaks of the importance that a country gives to its women. However, the infant mortality rate also speaks of this reality, since these deaths are also suffered by women—often within their own bodies.

Infant mortality includes the deaths of infants under 1 year of age. Costa Rica’s infant mortality rate for 2019 was 8.25 infants for every 1,000 births; for the first trimester of 2020, that rate had increased to 9.19 per 1,000.

Like Costa Rica’s maternal mortality ratio, this indicator, although very good for the region and the world, has fluctuated significantly over the last two decades. It reached 10.05 in 2007 and 7.74 in 2015, the year my son’s file became part of the Ministry of Health’s ongoing studies.

For 2019, INEC reported that 51.3% of the deaths of children under one year of age were due to “conditions originating in the perinatal period,” the weeks immediately before and after birth. These conditions refer to health problems that developed after 22 weeks of gestation. Almost half of these deaths occurred due to births of “extreme immaturity”—that is, infants born at under 28 weeks’ gestation.

The other significant cause of death in Costa Rica is congenital malformations, which represented 33% of deaths in 2019.

The prevention of infant mortality depends on the complexity involved in controlling the causes of death. Infant mortality has been declining worldwide because causes that are easier to address, such as immuno-preventable diseases, acute diarrheal disease, and acute respiratory infections, have been controlled. Perinatal conditions and congenital anomalies are harder to deal with.

Studies of the global infant mortality transition show that when a country that has managed to reduce its infant mortality rate to the minimum possible and is in the sixth and final stage of this transition, this is because the primary cause of infant death is congenital diseases, followed by perinatal diseases.

Again, Costa Rica falls just short of reaching the infant mortality rate it needs to enter the final transition stage—sixth, in this case.

These same studies, by Alejandro Aguirre, show that “to avoid deaths from conditions originating in the perinatal period, more costly measures are required, such as adequate prenatal and medical care during delivery. This requires hospital infrastructure as well as trained human resources ”.

Costa Rica has this structure, and also a strong culture around public health. However, the availability of resources varies throughout the country. For Dr. Arguedas, the clear inequality exists in women’s treatment from region to region. When a hospital has a single OBGYN, that means everything depends on that one person,” she said. “There are hospitals where problems are generated in certain shifts or because of problematic people.”

Prevention

El nacimiento de mi segundo hijo. Fue un parto vaginal a pesar de que tuve una cesárea de emergencia con Martín. Recibí cuidados y monitoreos extra. Pero a pesar de mi historial, me segundo hijo también estuvo en peligro cuando en el hospital me insistían que debía volver a la casa porque “él todavía no puede nacer”. Claro, esa no es una decisión que tomamos nosotros, mi esposo y yo insistimos, mi hijo estaba naciendo. Fotografías por la fotógrafa y artistas Pamela Fuster. Cortesía/El Colectivo 506

For many reasons—some that I do not understand, others that I do not approve of—these tragedies are often surrounded by silence and secrecy. They carry a stigma. They are difficult to handle. That’s precisely what my therapist was trying to explain when she said that infant and maternal mortality bring birth and death face to face: it’s a potent combination that many prefer not to speak of, to ignore.

However, the reality is that these deaths have an impact that goes far beyond the hospital ward, ambulance, or home in which they occur.

“A [maternal] death is a tragedy on multiple levels, it is not only the death of the mother,” said Dr. Arguedas. “It affects the immediate family and the community; it cannot be understood just by thinking of the individual.”

If you ask me, the death of a child under one year of age has the same impact on all these levels.

Although maternal mortality and infant mortality are studied as separate indicators, it is clear that their prevention is related. In Costa Rica, since 1996, there has been a National System for the Evaluation and Analysis of Maternal, Perinatal and Infant Mortality created to “study and analyze every death that occurs in the national territory, in order to formulate, recommend and define public health policies, recommend programs and actions to improve the care that contribute to maternal, perinatal and child health based on in the existing regulations.”

The system works through analysis commissions at different levels under the leadership of the Ministry of Health. I myself was part of those analyzes after the death of my son Martín. It was an unexpected, sad, strange interview in a room where my questioners were two empathetic women, but despite that, I felt I had to justify myself. My curiosity about how authorities use this data to avoid future tragedies was part of what led me to write this story. At press time, I had not yet obtained a response about the progress made by this system and its commissions towards reducing infant and maternal deaths.

However, in its institutional documentation, health authorities from the previous presidential administration did mention some of the challenges faced by the system, especially in eradicating “poor treatment or dehumanizing practices in childbirth and pregnancy care” by health service providers, and ensuring that the recommendations that come out of the commissions are binding.

Women don’t want to go to hospitals to give birth,” said Dr. Arguedas. “If all your cousins, friends, sisters, have horror stories from hospitals, you’re not going to want to go.” For her, eradicating obstetric violence in all stages of pregnancy, and achieving quality prenatal and postnatal care, are the elements needed for Costa Rica to avoid preventable maternal and infant deaths.

Dr. Carranza’s study of maternal mortality between 1984 and 1996, and a similar analysis 15 years later, showed delayed care of pregnant women was the reason behind many maternal deaths. “These women arrived on time [to the clinic] when they felt ill. Some were not diagnosed at all. Some were made to return home. Many went [to seek care] many times,” but they were not diagnosed in time to prevent an emergency situation. She added that it is important, when a pregnant woman arrives at a health center, to ensure “a quality medical history, a quality physical examination. Take the time to be able to diagnose what is happening and what will be treated.”

Progress in reducing maternal and infant mortality in Costa Rica depends on the quality of the health services provided, but it is important that this improvement is not interpreted as the medicalization of pregnancy and childbirth, where everything can be resolved with medical procedures such as cesarean section or induction. The WHO points out that countries like Costa Rica that have comparatively low maternal mortality have often achieved this decrease due to the medicalization of labor.

Another challenge that Costa Rica faces on this issue, according to the 2014-2018 institutional review of the Ministry of Health, is the importance of creating regulations “that guarantee the development of intercultural health models of health services, with cultural relevance, from an integrative health perspective that contributes to reducing inequalities.”

Peru offers a success story in this regard. The country managed to reduce its maternal mortality from 258 to 68 deaths per 100,000 births, between 1990 and 2015. Among many reasons, some negative, this advance is attributed to Peru’s success in adapting health services to the cultural choices that many women of indigenous cultures make using facilities called Casas de Espera (literally, “Houses for Waiting”). These practices include allowing women to be accompanied by their whole families and even their animals and allowing vertical delivery, where women do not lie down to deliver. Because of these changes, women who did not want to approach health services in the past now do so. This shift has saved many lives.

Costa Rica’s challenge

Any woman and mother who has walked the path of tragedy and mourning with me know that these losses are never forgotten. Not for a second. That experience, that loss, is part of how I see every part of my life. Despite that, only now have I been able to lift my gaze and look outside my experience to understand the sheer number of factors involved in determining whether mothers and babies live or die in a given country. The way these issues affect, and are affected by, the way we live, migrate, work, educate, coexist with other cultures, coexist with the opposite gender.

The WHO notes that the main challenge for a nation seeking to avoid all preventable maternal and child deaths is “the consolidation of advances against structural violence (for example, gender inequalities), the effective management of vulnerable populations (for example, immigrants, refugees and displaced people in their own country) and the sustainability of excellence in the quality of care.”

A few months before I went into labor with my first son, a well-known doctor in Costa Rica told me that although giving birth is natural, things can go wrong very quickly. That phrase has stuck with me ever since because the death of my son happened just like that.

It is important to point out that the prevention of maternal and infant mortality begins with recognizing the consideration due to the pregnant woman: not only allowing her access to prenatal, delivery, and postnatal care, but also ensuring the quality of that care, and that it prioritizes her needs and the needs of the child. When health care centers are better equipped to care for women’s emotional needs, pregnant women will be more willing to come closer to these institutions and to be empowered participants in their prenatal and postnatal control, thus avoiding preventable deaths.

As for me, I invite all of us to talk about these deaths. We must bring this issue out of the shadows, beyond the numbers. We must speak more openly and publicly about tragedies that should not, must not, be relegated to the anonymity of statistics. We must shine a light on these losses that touch every aspect of our lives. These moments when birth and death come face to face and, as they gaze upon each other, raise their voices to tell us something real.

Photographs during my pregnancy with Martin by photographer and artist Pamela Fuster. Courtesy/El Colectivo 506