Wednesday, June 04, 2008

Life's guarantees

I was reading posts on AP on cord blood banking, home births and multi-fetal reduction and it came to me that the birth culture today, with the advent of technology and advances in research, now offers us so many more choices and tantalising hints of guarantees of perfection. And yet, is there a price to pay? Are we really better off with so many choices? Can we really play God and get away with it?

Today, we seek perfection. We seek choice. We want to live longer. We want to cure diseases and illnesses that were previously incurable. We want to walk on the moon and live on Mars. What once seemed impossible is no longer improbable.

The knowledge and technology that seems so wonderful, that can tell us so much, give us a window to the womb, allow us choices like never before, is also a double edge sword. New ethical dilemmas are spawned. It’s like Eve bit the apple all over again.

Take IVF for a start. The potential to create life outside the womb is an awesome power, once only the prerogative of the gods, now lies in the hands of humans. We now decide how many embryos to implant, their gender etc. And if the number who survive in the womb are too many, what happens? Terminate one? Two?

And what happens to those embryos not implanted? Those are rich in stem cells too. Are those lives, tiny though they may be, expendable? We are back to the old debate on when life actually starts. Now there is preliminary research into the possibility of 'designer babies' with parents possibly faced with choices of the genetic traits they want to include or avoid in their babies. Where will it end?

Then we have prenatal testing to screen for imperfections and abnormalities, with the option to terminate when we find or suspect an imperfect baby.

No prenatal test guarantees accuracy but yet this has opened the doors to unwanted imperfect babies being terminated. Yet, how many babies have been 'terminated' who were later found to be normal? Or the other way around - how many babies claimed to be 'normal' were later found to have some undetected abnormality? How does this impact the parents? How do parents then see their children?

Prenatal testing never guarantees but always raises doubt. Even if a test declares the baby to be 'perfect' and 'normal', a couple may never be reassured that this is so. Would there always be lingering doubts and fears? And for couples who choose to terminate, how terrible and painful a decision to make. A mother, having felt her baby move at 16 weeks, 20 weeks, and then to make the decision to terminate based on the results of a test, how much grief, anger, suffering, doubt she will go through in the future?

We use ultrasound routinely to look within the womb, in search of signs of imperfections and abnormalities, to identify gender and now, with 3D scans, to help parents 'bond'. We have ultrasounds that tell us the size of the baby and from there, whether a C-sec is recommended or not. But ultrasounds are not always accurate. How many babies have been diagnosed to be ‘big’, recommended for C-sec, only to be discovered to be smaller than diagnosed?

With the ultrasound to determine gender, gender selection via abortion is common in countries like China and India. If that seems extreme, it really isn't. Even within the ordinary settings of a doctor's office where a worried couple sit on tenterhooks waiting for their doctor to give them the news - how anxious they may be, how this colours their view of their pregnancy, their baby.

In labour and birth, we have a whole arsenal of tools, tests and interventions at our disposal to try to ‘minimise risk’ of adverse outcomes.

We have the CTG to try to detect fetal distress to arrest the rate of fetal mortality and morbidity - which at least 8 to 9 different studies have shown not to be effective in doing so but has contributed to a high c-sec rate.

Induction rates are high with figures from the US showing that most pregnancies end now at 39 weeks instead of 40 weeks thanks to inductions and elective C-secs. We do not trust the body to go into labour spontaneously but induce at the mildest of reasons: try the following “my doctor will not be here/is on holiday”, “I am already 2cm dilated, so might as well do this” or “you are due today anyway!”

We put a timeline on labour and then augment it if it seems to lag behind manmade deadlines. We break waterbags, cut episiotomies and freely offer drugs, no longer trusting our bodies to cope with its own signals. We do all this in a bid to turn labour and birth from an unpredictable life event to one which can be 'safer' and more 'controlled' or 'managed'. What used to be an emergency procedure to save the lives of babies and mothers in distress, the C-sec is now used almost routinely for breech births, multiples, big babies, repeat C-secs, for mothers too posh to push or for doctors who prefer the fee and the convenience.

The medical community has the best of intentions. No one faults the intent. It honestly believes that birth and labour are processes fraught with risk and so it earnestly comes up procedures and interventions designed to minimise the uncertainty and the risk of birth. We attempt to 'manage' birth - to make the messy manageable, impassive and clinical. Along the way, home births died a quiet death, midwifery-led care faded into the wallpaper, specialist ob-gyns now manage normal births, hospital births and interventions become the accepted norm.

What we have seen so far is that the outcomes are not distinctly or significantly better. The C-sec rates have gone up, so have inductions, augmentations, operative births. Epidurals are popular. Medical cost has gone up as well. Maternal and fetal mortality and morbidity may have declined (though whether that is due to active medical interventions or better infection control and sanitation/hygiene practices is debatable!) but has maternal well-being improved - particularly if well-being is gauged by emotional yardsticks of satisfaction, fulfillment, self-confidence and empowerment?

With the active management of third stage of labour, comes immediate cord clamping and cutting, we now have the advent of cord blood banking and all its tantalising promises of miracle cures, now and in the future.

A managed third stage is relatively new in human history terms - about the last 50 or 60 years – a mere teensy drop in human history. In these 50 or 60 years, we have opted to hasten the 3rd stage, clamping and cutting the cord immediately at birth. The consequences of this have been established and shown in various studies – lower blood pressure, lower blood volume, poorer oxygen saturation, lower haemoglobin, lower iron stores even in the later months of babyhood and speculatively, brain cell damage due to poorer oxygenation and profusion at birth.

And now, thanks to active management of the 3rd stage, the cord is now considered a 'waste' by-product of birth. Something that for millenia, has fulfilled a vital purpose in kick starting life for the baby, is now considered 'defunct' and a 'waste'. How can that be so? How can so many thousands of years of human history and natural selection be wrong? Why do we underestimate and undermine nature's design?

So some bright spark out there one day put together the idea - stem cells = cord blood. Since this is considered a 'waste' anyway, let's make use of it. Hence the emergence of cord blood banking.

I don't deny that stem cells are potentially useful, but so is the cord blood for the baby. What I find even more worrying is that big business has now entered the picture while complete informed consent has been hidden by the glossy brocade curtains of emotive advertising. Are couples told about how cord blood serves the newborn? Do they know the necessity of cord blood to the baby? Can there be other sources of stem cells? To answer that last question - yes, there are other sources, in the bone marrow for instance. But it is easiest and most convenient to harvest cord blood than to do a bone marrow donation.

So we have prenatal testing to sieve out the imperfect or the unwanted. Then we bank cord blood as 'insurance' against a potential incurable disease in the future. But life holds no guarantees. That perfect child who shows no sign of Downs in the amnio might later develop autism, or ADHD or schizophrenia or bipolar disorder? Who knew?

That child whose cord blood is banked may later end up killed in an accident, a plane crash? Who can tell? What happens to the picture of the 'perfect child' then? Is there such a thing as ‘perfection’?

Yet, as a parent myself, I can understand the impetus - who would not want to save their children? Who would not want the best of them, for them? Who would want them to lead a life of burden? So we try to 'save' them – but is that our role as parents? Or would we be better off accepting what comes and cope as bravely as we can with whatever life throws at us, perhaps developing along the way, an optimism, a faith, a trust that a Higher Power will provide what is best for us and for our children's lives? In doing so, do we then teach our children by example, about resilience and strength.

Everything has its time and place, everything has a season and a reason. Trusting in God, Allah, the Universe. Whatever happened to all that? Life is messy. Birth is messy. The only certainty we have in life is death. So why are we so afraid of this? Why do we fear the uncontrollable? Why do we seek power to manage life and all its unpredictability?

We seek guarantees and promises but life offers us none. The more we try to manage all this, the messier it gets and somewhere somehow, a cosmic cookie cart comes unhinged and cosmic cookies roll all over the place.

If we understand that all we have on earth is a finite time, accept all that has been given to us, the challenges, the dreams, the hopes, the fears and work with all this that we have, why would we fear death or the unknown? And then work so hard to tweak or game the system. No wonder that mankind's obsession with control issues have led to interventions on many levels - from birth to global warming.

What price our quest of guarantees, promises and insurance? There are no umbrellas in life. Best to just play in the rain.

1 comment:

eelin said...

hi pat
i have so many thots on this ... but i will just relate one story. a couple from my church had a 2nd baby that from ultrasound scans early in pregnancy showed that there was some serious abnormality in the devt of its brain. the doc gave them the option of termination ie abortion as the defect was serious, probably fatal or completely debilitating. they prayed and carried the child, a boy to almost full term, birthed the boy and named him before he died the next day. when the mum was pregnant, my dh who first found out abt the 'story' wld shake his head and said why are they going thru with this and why is their cell group and the church supporting them in this decision. but when we saw the notice in the church bulletin abt their baby's birth n death all in one sentence, i told dh they did the right thing. this way, they had a baby to name, to hold even for a short while, to mourn, to grieve. they could always say, we had a son, his name is ... he died but we'll always remember him or we'll see him one day, perfect, as he was meant to be. if they had terminated the pregnancy they'd be left with nothing but doubts. i thot it was so very brave of them to carry the baby to full term. after a short silence, dh agreed, yes you're right. just thot this sharing was apropos with your post. you're right, there are no guarantees. all we can do is to accept that life is messy, is not what we'd always want. sometimes it trips us up, sometimes it really hurts.
Ee Lin