Following the death of Everline Namukhula, barely eight days after losing two of her quintuplets, Dr Wala Elizabeth, a mother of triplets, highlights why mothers who give birth to multiple babies need special care, and how they and their babies could be helped to live healthy.
The radiographer’s face changed from business-as-usual to perplexity as he moved the cold wet probe of the ultrasound machine over my lower abdomen. “I can see two sacs. Both at 11 weeks of gestation. Oh wait, here is a third one!”
I nearly jumped off the couch in shock! I had anticipated twins. Having had the experience of carrying a singleton (my first born), I thought the severe morning sickness I was experiencing with this second pregnancy was abnormal. It most likely meant that the hormones produced were above the normal range and that’s why I predicted twins. But triplets? What will I do with triplets? Will I even survive the pregnancy?
As a medical doctor, the risks of a multiple pregnancy were made alive at that moment. The news of carrying triplets brought more panic than happiness to me. But I had the privilege of a private obstetrician, private insurance cover and a strong social support system.
One in five twins born in sub-Saharan Africa dies before age five, a likely conservative estimate. Twins are far more likely to die before one month of life than singletons and three times more likely to die under five years.
Multiple pregnancy is the result of complex interactions between genetic and environmental factors. Apart from hereditary factors, its unequivocal risk factors are the use of assisted reproductive technology (ART), older maternal age, and advanced parity.
I am often asked, “Are they “natural”?” My reply, “No, they are plastic babies. They just feel and behave like natural children.” I say it with all good intentions because parents with multiples often find this question an intrusion into their privacy, as it doesn’t really matter how the children came to be.
Multiple gestation is considered a high risk as it is linked with various obstetric complications, including spontaneous abortion, hypertensive disorders, placenta previa, abruption, mal-presentation, malformations and cerebral palsy.
Prevent transmission
During my pregnancy in 2009/2010, my search for local support in terms of information was nearly nil. Every online site was based in the west and many socio-cultural issues differ.
Mothers carrying multiples should be referred for delivery at specialised centres, where advanced obstetric care is available, and receive proper prenatal counselling. Hospitals where the multiple gestation deliveries take place should be adequately provisioned to do caesarean sections if needed and the staff should be trained in neonatal resuscitation and care for premature neonates.
In the quest towards Universal Health Coverage, we realise such pregnancies are often overlooked with regards to the kind of quality of care needed. First, the current free maternity programme, Linda Mama by NHIF, limits antenatal visits to four per pregnancy. It also does not provide for an ultrasound.
Multiple gestation pregnancy is always a high risk and thus will require more than 4 visits.
In Kenya, we only have one maternal-foetal medicine specialist based at a private facility in Nairobi. The Multiples To Multiples Society appreciates the role he has played in supporting the few families who can afford private services from that facility.
The society has a psychosocial team that endeavours to support new mothers especially with breastfeeding and during weaning. Many of these families are struggling to put food on the table and we have lost a number of babies from malnutrition.
I remember a case of twins brought to our attention. The teenage mother was HIV positive and had been instructed, as is the case, to exclusively breast feed the twins to prevent transmission. Both the mother and the twins were on drugs to prevent the same. Due to poverty, the mother had started defaulting on the drugs since she could not afford regular meals every day. This posed a danger to the children in terms of exposing them to the risk of transmission. Our society mobilised resources to support her for the first 6 months to ensure she continued with the drugs and exclusively breastfed. The twins have remained HIV negative.
One of the biggest cost burdens to raising multiples is during delivery. Since multiples are more often than not born prematurely, private medical insurances do not cover this.
We have seen medical bills of close to Sh10 million arising from the care of preemie set of quadruplets in one of the private facilities. We direct all our expectant parents to have an NHIF cover and visit a facility that offers the Linda Mama comprehensive package.
Cultural issues surrounding multiple births are numerous. I remember my obstetrician jokingly telling me that I needed to have a singleton after my triplets were born to “close my womb properly”.
A set of twins in Bungoma County was deliberately left to die because they were considered a curse. The newborns died when their mother was barred from entering her house by her father-in-law before special rituals were conducted to ward off the bad omen that the babies’ birth allegedly portended.
So, the work is cut out for us. Therefore, without addressing social-cultural issues affecting families with multiples, we will continue losing mothers and children.
Our Multiples To Multiples Society was founded in 2013 to offer support and a platform of sharing with other families who have or are expecting multiples. The society is the only of its kind in Africa and has an impact far much wider than our Kenyan borders. Membership is now close to 2,000 families and guardians of multiples. We have walked with families who have just discovered they are expecting multiples, we have mourned with them when some of the babies have died either in pregnancy or infancy.
We have encouraged mothers to take extra care of themselves by having professionals within the group answer all their mundane questions.
We have supported families with children born with special needs by referring them appropriately. We have celebrated each birthday and milestones brought to our attention.
The writer is founder and chairperson of Multiples To Multiples Society [multiples2multiples.org]