The Preamble, Recommendations and Conclusion of the 305th Inaugural Lecture of the Obafemi Awolowo University, (OAU) Ile-Ife, Osun State, delivered by a Professor of Obstetrics and Gynaecology, Professor Olabisi Morebise Loto.
Preamble
Mr. Vice Chancellor Sir, Principal Officers of the University, Members of the University council, Members of Senate, Provosts, Deans, Directors, Heads of Departments, Invited guests, Gentlemen of the press, Distinguished Ladies and Gentlemen.
It is with immense gratitude to God Almighty that I stand before you today to deliver the 305th Inaugural Lecture of the Obafemi Awolowo University, Ile-Ife. I am grateful to this University not only for giving me the opportunity to be a student but also for providing the platform for me to be a practising scientist who through the pursuit of academic excellence and the unlimited grace of God is contributing immensely to solving some health challenges within and outside this epistemic community. I am thankful for this occasion to be counted among the erudite scholars who have given inaugural lectures in our Citadel of Learning. This Lecture is the fourth from the Department of Obstetrics, Gynaecology and Perinatology. The first, titled ‘Efforts at Making Pregnancy Safer’, was delivered by Professor S.O. Ogunniyi of blessed memory. ‘Journey Within the Tunnel: Women’s Health Care and Interventions’ is the title of the second lecture, which was delivered by Professor O.B. Fasubaa while Professor E.O. Orji delivered the third lecture titled ‘Opening the Womb of Life: An Adventure of an Obstetrician and Gynaecologist’. These are all erudite scholars, renowned clinicians and trail blazers whose footsteps I try to follow as I give today’s Lecture.
Mr. Vice Chancellor Sir, the journey to this podium did not come by the will of man. I never wanted to partake of the ‘publish or perish syndrome’ associated with academic career. Having graduated from the Obafemi Awolowo University Medical School as the best student in surgery and surgical specialities, all I wanted to be was a specialist rendering care to patients. But then, Prophet Jeremiah aptly captures my odyssey, when he said: “...no one is the master of his own destiny: no person has control over his own life” (Jeremiah chapter 10 verse 23: Good news Bible). Thus when I heard the call of destiny in both the consulting room and the classroom, I yielded wholeheartedly, treating patients tenderly and enthusiastically as well as teaching students diligently and unreservedly. In doing so, I have become not only a good care-giver but also a great candlestick that lights others in the field of Obstetrics and Gynaecology. Mr. Vice Chancellor Sir, every candle of greatness, however, has a source. It is like a divine thread in human tapestry, comprising both God and human elements. My choice of Obstetrics and Gynaecology is a function of God and the people whom He placed on my path as teachers. Given that I was the best graduating student in Surgery, rationality and cerebral logics offered me Surgery but revelation gave me Obstetrics and Gynaecology and to the glory of God, I had a quantum leap to the echelon of the specialty and became Professor of Obstetrics and Gynaecology within a period of eight years of joining the Department.
Certainly my choice of and exploits in Obstetrics and Gynaecology are also traceable to the influence of great teachers whose commitment to the teaching of the subject stimulated my interest in the field. To this end, I am eternally grateful to all my teachers from the preclinical to the residency days. Professors Onwudiegwu and Ogunniyi deserve special mention. The former admitted me into the residency programme in October, 1995 to be trained as a specialist in Obstetrics and Gynaecology, a programme I completed in a record time of 4 years in October, 1999, while the latter recruited me into the academic Department in September, 2005 having worked as a consultant at the Federal Medical Centre, Owo from 2000 to 2005.
The agonies of our mothers, sisters, wives, nieces, and aunties in labour, including an obstructed labour need a compassionate heart. The unimaginable dilemmas and pains of couples grappling with difficulties of infertility demand a caring hand and a compassionate heart. The joy of seeing a woman in labour suddenly smiling with her baby by her side after a successful vaginal delivery or caesarean operation and the glowing faces of couples who moved from being infertile to become expectant parents are all unquantifiable psychological rewards. For over a decade, I have been caring for these categories of patients. My daughter, when she was just five years, once asked me, ‘Daddy why do you treat only women? When I grow up I will be a doctor and I will treat everybody.’ Mr. Vice Chancellor Sir, the answer to her protest-cum-question lies in the fact that women bear more burdens of pregnancy and infertility than men. Obstetricians and Gynaecologists are not only physicians and surgeons, they are both combined. They are also advocates, human right activists, counsellors and maybe priests, all in one. As a result, every Obstetrician and Gynaecologist wears a coat of many colours, albeit without any colour riot. Therefore to render an account of my academic stewardship in the field of Obstetrics and Gynaecology, I have come with my coat of many colours, reflecting in the title of this Lecture: ‘Give me children... Let me live: Combating the Misery of Infertility and Preventing Maternal Mortality’
Recommendations
My recommendations as I end this Lecture are directed to three groups of people; the individual, the healthcare providers and the government and policy makers.
1. Concerning infertility, prevention is clearly better and cheaper than cure Prevention is achieved through the avoidance of risky sexual behaviours that leads to pelvic infections, unwanted pregnancies and its termination as well as delivering babies in unhygienic places, which may lead to puerperal sepsis. Also living healthy lifestyles, such as avoiding alcohol, smoking and unhealthy dietary habits will help to reduce the risk of infertility.
2. Health care providers should use every opportunity to canvas for healthy lifestyle and talk about prevention. They should avoid unnecessary pelvic operations in young women and manage pelvic infections promptly using the recommended evidence based guidelines.
3. Couples with infertility problems should always seek medical services early in government approved hospitals. This is because in trying to treat infertility women may be subjected to numerous ineffective treatments which are expensive and time consuming by quacks and even some supposedly professionals. This is not only prevalent among alternative health practitioners, but qualified medical personnel are also guilty of this. The end result is an increase in the misery and financial problems of these hapless couples. It is unacceptable and totally unprofessional that in this era of evidence based medical practice, people still use modalities of treatment that have been found to be ineffective and sometimes harmful .In the case of an infertile woman, any time wasted on unnecessary treatment is harmful because her biological clock continues to tick each passing day with each tick representing a stroke in the dimming of her hope for fertility for life as it pulls her towards menopause. So it is important that professionally acceptable treatment be used for the woman as early as possible.
4. The government and policymakers should ensure that our hospitals are not merely consulting clinics but a place where there is provision of adequate funding for the procurement of standard equipments and staffing.
5. Government should set up highly subsidised IVF Units to manage the infertile couples whose only option is IVF for the resolution of their infertility problems. The cost of accessing this treatment still remains prohibitive because infertility treatment is excluded from the insurance scheme and couples have to pay out of pocket. To this is added the cost of transportation and lodging as most of the IVF centers are located in the big cities of Abuja, Lagos and Port-Harcourt. While so many NGO’s spend millions of dollars on family planning to reduce the population, none is spending money to help infertile couples achieve their aim of parenthood. It is unfair to impose the burden of over-population on women and men suffering from infertility as all children contribute equally to the problem of overpopulation and not just those born from fertility treatment (FIGO 2015). Also, overpopulation bears its fangs on all, fertile or infertile.
6. Family-planning and infertility are clearly linked and should be handled in the same centres. Public education on prevention of infertility includes not only prevention of STDs and pregnancy-related infections, but also life style factors, such as iatrogenic infertility, environmental pollution and contamination. Health education programmes are essential and should be encouraged at appropriate levels and be carried out by appropriate individuals and institutions.
7. Infertility treatment should be part of an integrated reproductive care programme including family planning and contraception, mother care, and reproductive health issues. We need to transform the paradigm of family planning into the planning of a family, and deploy human and material resources into helping infertile women and men become loving and caring parents.
8. Raising awareness is another very important issue and should be done with great care. It is important that focus must be on changing the existing moral and socio-cultural beliefs to a level where childless couples are no longer isolated, stigmatized and discriminated against. The media, patient organisations and interested politicians are needed in this regard. This will definitely not be a stroll in the park; obstacles will be numerous depending on local sociocultural, political and religious influences but it is achievable by all standards. Providing infertility care in developing countries can only be successful if we are able to diminish the sociocultural, psychological and economic consequences of unwanted childlessness.
In the prevention of maternal mortality, my recommendations are also directed to the three levels above; individuals, healthcare personnel, government and policy makers.
At the level of the individual, the pregnant woman should always be prepared, knowing that pregnancy is a nine month journey (birth preparedness and complication readiness). She and her husband should put some money apart in case of emergency and also liaise with a transporter for emergency transportation at night, if need be.
Health providers should constantly update their skills and knowledge so as to be aware of the current evidence-based best practices in the management of pregnancy, labour and delivery. They also need to improve their relationships with patients and their relatives so that they do not, inadvertently, drive them away from the hospital as a result of their attitude.
The government and policy makers need to make sure that our hospitals do away with the mere consulting clinic status that they have come to be known for over the years. They should be transformed to real functioning hospitals by improving on the funding, infrastructural development and the human capital development in these hospitals. The government also needs to expand the National Health Insurance Scheme (NHIS) to cover more of the populace as well as provide more therapeutic interventions to reduce the crippling out of pocket expenditure by patients.
Conclusion
Mr. Vice Chancellor Sir, the causes, consequences and cure for infertility as well as how to prevent maternal death are clearly highlighted in this Lecture. The causative factors in maternal mortality in Nigeria can be divided into four: medical, socio-cultural, health service and reproductive factors. Socio-cultural factors contributing to maternal mortality include low status of women, poverty, poor nutrition [in childhood, adolescence and adulthood], ignorance/illiteracy, religious beliefs [that act as barriers to utilization of available health services] and harmful traditional practices.
The health service related factors are numerous and include lack of access to essential obstetric care, lack of access to family planning [FP] counselling and service, lack of drugs, blood, equipment, essential materials, instruments, consumables etc in hospital, non-availability of health workers on essential duties caused by incessant strikes, deficient transportation, communication and utility (power, water etc) facilities.
These factors often act synergistically to produce fatally skewed consequences. Women are discriminated against when they are in an infertile relationship and neglected when pregnant and about to give birth. When their prayers are eventually answered, we should ensure that the woman does not end up dying. Even when they say, “give me a child, let me die”, it is a not a voluntary death. Women have been handed the short end of the stick and infertile women the shorter end. They are culturally disadvantaged, emotionally abused, economically subjugated and psychologically subdued. But the strains of insanity present in the mind of an infertile person caused by societal abuse and stigmatisation only mirrors the mental stability of the society as the accuser.
Mr Vice Chancellor Sir, according to Mahmoud Fathalla (2013) we owe these women of the world an apology. We express our regret and we confess our guilt, although we cannot dare to ask for or expect forgiveness. Mothers sacrificed their lives when we had no means to save them. But after the world had the knowledge and means to make motherhood safer for women, mothers in many parts of the world were left to die in the line of duty, because the world turned a deaf ear to their screams.
An inconvenient truth is that these mothers are not dying because of conditions we cannot prevent or treat. To put it bluntly, they are dying because societies had yet to make the decision that their lives are worth the cost of saving. The tragedy of maternal mortality is a question of how much the life of a mother and a woman is worth in the collective psyche of leaders, fathers, policy makers, healthcare givers and the society at large. The economic invisibility of women unveils itself in that their works, much as it counts, is not counted. Few women are in decision making capacities about the allocation of resources, particularly in countries where these resources are scarce (Fathalla, 2013).
These dangerous consequences women faced during childbirth are exemplified in our African folklore in which a mother tells her children, “I am going to the sea to fetch a new baby; the journey is dangerous and I may not return”. Many are still not returning today.
Mr. Vice Chancellor Sir, “women’s lives matter”. This Lecture has offered both curative and preventive measures. It is the obligation of health workers, policymakers and husbands to contribute positively towards safe maternal health so that every woman who goes on the nine-month journey will return no matter the degree of danger involved. Therefore, health workers need to continually update their knowledge of the current best practices in the speciality as it affects management of patient. It is generally believed that half of what is printed in textbook is out-dated by the time the book is published, but the problem is that we don’t know which half. This is the era of evidence-based medicine and hence all practitioners must be able to make use of the outcome of systematic reviews in making clinical decisions. It is well recognised that knowledge reduces as years go by after graduation from medical school. Hence, doctors will need to regularly update themselves to keep abreast with the developments of international best practices in their specialties.
When practitioners fail to update themselves, their knowledge of evidence-based current practice reduces with the passage of time. The chart in Figure 32 presents this claim vividly.
Health education is highly important. Institutions in charge of disseminating moral codes, ethics and etiquette must rise up to their responsibilities. Infertile couples should be encouraged to seek scientific solutions. Government should set up highly subsidised IVF Units to manage infertile couples whose only option for the resolution of their infertility is IVF.
Insanity according to Albert Einstein is doing something the same way and expecting a different result. We have been running our health institutions the same inefficient way for too long, and we still expect results. Wisdom is the correct application of knowledge. Various researchers have generated knowledge; yet as a country, we lack the correct application. Little wonder then we still have pitiable health indices when compared to those of other countries. To this end, Mr. Vice Chancellor Sir, I am persuaded that implementing the recommendations of this Lecture at individual and institutional levels will change the grim statistics and lead us to the Promise land, where none shall be barren; where none shall cast their young ones; where no pregnant mother will be buried; where all who enter into labor shall live to enjoy the fruit of their labour.
Mr. Vice Chancellor Sir, Distinguished Ladies and Gentlemen, I have presented to you my account of stewardship in this race to safeguard our world from extinction by helping our women to become mothers safely. In our daily professional interactions with patients as obstetricians and gynecologists, the voice of Rachael will continue to resonate in the voices of men and women battling infertility. My opinion is that we must listen with our inner ears and be empathic in our listening. We must hear this as a plea to be helped, to be saved from shame, disgrace, and ostracisation. Even when they say “give me a child…or I die” or “give me a child…let me die”, we must hear this passionate plea as “give me a child…let me live”.
I thank you all for your presence and attention. God bless you all.
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