From pregnancy to contraceptives, everyone must be allowed to choose

Sooki* is one of those patients you prefer to see at the end of the working day. We have an unspoken understanding that her appointment is usually booked as the last one. This is because her consultation inevitably veers off from clinical issues to social ones that last for over an hour.

This precedence was set on the first visit when Sooki walked into my office, pregnant with her fourth child and terrified for her life. She had undergone three rollercoaster pregnancies that required a caesarean section delivery, with the last one ending up with a ruptured uterus that nearly killed her. Despite the uterus being repaired successfully after the miraculous rescue of the baby, the doctor warned that the scarring would not permit the carrying of another pregnancy to term. She had been advised against any further pregnancies in view of the threat to her life.

Unfortunately, contraceptive use had been a challenge for her. She had been put on the copper-based intrauterine device as a last option and it worked well for four years before the undesired failure happened.

Unfortunately, Sooki and her doctor did not agree on the way forward. The doctor thought it was too risky for Sooki to carry the pregnancy to term as it might result in her death and advised her to terminate it. But, she opted to carry her baby to term.

The doctor preferred to refer her elsewhere for care as he did not feel adequately equipped to deal with the possible any likely complications. He was elderly and of failing health.

Sooki chose her new doctor and that is how she landed in my office. I must admit that no one is fully equipped to handle what we were facing with Sooki. To give her the best shot at a good outcome, we had to agree with her to co-opt a team for her care, bringing on board two more doctors fully available and accessible to her in case of an emergency.

She had to book for her delivery at the hospital very early on so that we were ready for her at all times in case things went south. Sooki enrolled potential blood donors in case it came to needing a transfusion. She signed up for ambulance services in advance, should she need it.

Things went smoothly until 27 weeks when we had our first scare. Thankfully, it was a minor issue and we were able to ride it out. By 32 weeks, Sooki was barely hanging on. She was in pain most of the days, requiring pain medication and spent more days at home than up and about.

TUBAL LIGATION

Through this difficult period, Sooki had to consider a decision that was very key to her. She had experienced contraceptive failure which had put her in harm’s way. We needed to explore a permanent method of contraception and a tubal ligation was sensible.

Sooki was all for the idea, but her spouse did not approve. Unfortunately, her mother-in-law supported him. Sooki’s husband was an only child. His mother wanted many grandchildren.

Sooki’s husband eventually came to the clinic and we had a lengthy conversation. He did not intend to raise his babies as a widower and as I enumerated the risks Sooki had to face to have this last baby, he was convinced this was the right option. However, so as to avoid unnecessary confrontation with his mother, who lived with them, the tubal ligation was to never be spoken about in her presence.

We were grateful to reach 34 weeks of pregnancy when we admitted Sooki for delivery. She stayed in the wards for a day to receive steroid injections to help the baby’s lungs mature and then underwent a C-section. The operating team had a urologist and a general surgeon on standby just in case we needed their expertise. Eventually, the general surgeon did have to scrub in and help but we were grateful the urologist’s expertise was not required.

INFORMED CONSENT

Both mother and baby came through fairly fine. Sooki required a blood transfusion, but she did way better than we had dared to hope. She went home secure in the knowledge that she had not missed out on a life-saving opportunity.

The lesson on Sooki’s reproductive health rights is not lost on all of us. Sooki, like all patients, exercised her right to information about her health issues, which was fully provided by her first doctor.

She had a right to opt out of the recommended treatment, however, this did not deny her the right to access the best available care within the limits she had set. For this reason, her doctor identified his limitations in providing the care and he referred her appropriately for the same.

She was participated in preparing the plan for her care, all measures that were required were put in place and she was aware of the response to be activated in case of an emergency. She had an opportunity to give informed consent for the tubal ligation. Though her spouse’s consent was not required for the procedure, every effort was made to involve him and support domestic harmony.

However, even if he had opposed the procedure, this was Sooki’s decision to make.

Last week, primary custodians of sexual and reproductive health and rights assembled in Kwale County to reaffirm their commitment to protecting these rights for all Kenyans. There is no better way to demonstrate commitment to patient advocacy than by leading from the front.

Dr Bosire is an obstetrician/gynaecologist