Where You Live Should Not Determine Whether You Live, or Whether You Die

Heidi K. Leftwich, DO

Where you live should not determine whether you live, or whether you die.” -Bono

According to 2021 statistics from the World Health Organization, 16 percent of maternal deaths in sub-Saharan Africa are attributable to hypertensive disorders of pregnancy. As a maternal-fetal medicine physician, I have spent my career caring for women with medical complications that impact pregnancy, with a focus on hypertensive disorders of pregnancy, including preeclampsia. Even in the United States, preeclampsia is a condition affecting approximately four to eight percent of pregnancies and a leading cause of maternal mortality.

Since the beginning of the pandemic, I have been working on a large research study looking at the link between the immunologic and histologic changes in the placenta from SARS-CoV-2 virus (the virus causing COVID-19) and its similarities to preeclampsia. When I was asked by a colleague and the Kenya Medical Research Institute (KEMRI) to come share my work and discuss ways to expand our research to collaboration in Kenya, I immediately thought it was an amazing opportunity to have the chance to impact care outside the United States. An avid traveler, I had never been to Africa, and I was excited about this opportunity. I quickly began making plans, as I did not have much time between accepting the offer and traveling. My colleagues were incredibly supportive, and they were instrumental in allowing me to participate in this incredible experience.

Since I would be in Kenya discussing research proposals, my schedule was starting to fill with meeting international researchers and going into the hospitals to talk with the local doctors about their needs and desires. I also reached out to the teaching hospital--which had three maternal-fetal medicine fellows--and was invited to give two days of lectures

Medical Missions & Volunteerism

during my visit. While there, I found out that there are only three people in the whole of Kenya who are fellowship trained maternal-fetal medicine physicians. My participation in the training of these three fellows would help Kenya actually double that number once they finished their training and graduated. I will say that I had incredible help from my mentor, who has been traveling to Kenya for 20 years and was therefore able to set up a full schedule for me to be truly immersed in both the culture and hospital system.

What I learned is hard to describe in a short narrative. I was so incredibly welcomed in the three hospitals I had the opportunity to visit, locally by the community, and in the medical training college in Eldoret where I taught the maternal-fetal medicine fellows, obstetrics, and gynecology residents and students. I was warned they may not ask questions out of respect for seniority but I was pleasantly surprised as our time led on that we had an amazing interactive teaching and learning model, where we all learned from one another.

One of my lectures focused on hypertensive disorders of pregnancy. I discussed the changes in guidelines that have helped decrease morbidity and mortality in the United States, and the standard of care and practice management. When asking questions regarding these guidelines and how they are managing similar patients, I quickly learned some of the barriers for their patients to adhere to such management, including access to the hospital, limited bed space, and refusal of inpatient care by patients because of family needs. A very important factor in offering management was that the gestational age at which a fetus was considered viable (able to survive) was closer to 28 weeks in their hospitals, compared to 22 weeks in the United States. This difference meant that, if a pregnant patient before 28 weeks came to the hospital for preeclampsia with severe features--a condition that can cause life-threatening hemorrhage, liver and/or kidney failure, seizures, and strokes-- the choice would only be termination of the pregnancy and not preterm delivery, something I recommend frequently for the sickest of my patients. This knowledge helped me better understand the culture and struggle in healthcare, so I could better formulate a research project that had a better chance of successfully making an impact.

In visiting three separate hospitals in Kenya, I realized also that all hospitals are not created equal. The amount of funds allocated to hospitals was somewhat dependent on the tribe and location; The teaching hospital in Eldoret had far more resources than the other hospitals I visited. As I discussed a proposal to test for preeclampsia, one smaller community hospital told me their chemistry machine had been broken “for a while” and they did not have the ability to check liver or kidney function tests on their hypertensive patients. This would be a barrier to a research protocol, but more importantly is a scary reality that hypertensive pregnant patients who present to this facility have less care than at other facilities. With so many life-altering experiences from my time there, this one sticks with me as the most memorable. How could this be? How could we help? Their option was to send “whoever appeared the sickest” as a transfer to another hospital to obtain these tests, but by then they may already be in liver or kidney failure. I saw transports when visiting the hospital that accepted such patients, with three cases of preeclampsia in one day, with two having stillbirths, two having renal failure, and one in the ICU after a seizure. If caught earlier, these outcomes could have been largely avoided.

Now that I have returned from Kenya, my next steps are to apply for grant funding to assess the need from a research study, showing what I clearly witnessed: a need for earlier, easier access to diagnosis and treatment, including helping to staff the centers with the equipment needed to take care of their patients. I hope to be back next year if my funding is successful and will pursue getting a full medical license next time so that I can help with patient care as well, not just from a teaching/research perspective. I am hopeful that I can fund the new chemistry machine from a grant, but, if not, I have plans to set up a fundraiser to buy the hospital the chemistry machine needed to help their healthcare providers have access to the equipment they so desperately need and desire. The words of one physician there will never leave me. I cannot imagine being in that position and making the decisions he is forced to make daily. I am forever changed by my experience in Kenya. The country and its people are forever in my heart.

Heidi K. Leftwich, DO is Assistant Professor, Obstetrics and Gynecology and Associate Fellowship Director in the Division of Maternal-Fetal Medicine at UMass Chan Medical School and UMass Memorial Health.