HIV IS HERE. PROTECT YOURSELF – GET TESTED.

...that’s the message written in big, bold, red letters on a billboard along the Freetown-Makeni highway.

According to the Populations Reference Bureau’s 2007 World Population Data Sheet, the 2005/2006 estimate for ‘Percent of Population ages 15-49 with HIV/AIDS’ for Sierra Leone is 1.5%. This is relatively modest, compared to an average of 3.0% for Western Africa, 4.5% for all of Africa, or countries like Zambia and Zimbabwe with almost a fifth of their 15-49 population living with HIV/AIDS.

All health care professionals here in Sierra Leone that I’ve talked with seem to think that HIV/AIDS in Salone is vastly underestimated. They attribute this to unwillingness of people to seek treatment, lack of education of HIV/AIDS and low coverage of education/testing/outreach efforts. I think the MoH has been stepping up on HIV/AIDS awareness and testing in the past few months/year(s – maybe). Well, it doesn’t actually matter when they decided to make the relevant policies – because the implementation has happened only in the past year – at least on meaningful scale (meaning outside the capital, Freetown, Makeni and Bo, the largest cities in the country). Last year, I have no recollection of being in a clinic and hearing of HIV/AIDS, but this year, testing is happening in all clinics I visit, and actively. The HIV/AIDS testing campaign is piggy-backing on our Pikin Welbodi program and has tested all children and caretakers in our program for HIV/AIDS. It was a bit of a hassle honestly for the HIV/AIDS people to interfere with our streamlined clinic process to pull people and children from clinic, but of course it was all worth it to hear that we were treating an HIV-negative population.

I was in Makeni last week and had the opportunity to join the Magbenteh Community Hospital TFC outreach team for one of their Outpatient programs (OTP) treating severely malnourished children as outpatients. This is the story of a child I met there:

So this girl, let’s call her Marie, had been treated last year at the Therapeutic Feeding Center for severe acute malnutrition as an inpatient. She was discharged no longer malnourished, but fell ill several times between after she was discharged and this year and became malnourished again. Her caretakers brought her to the OTP site several weeks ago to be treated for malnutrition. Marie is a “sickly child,” according to her mother. Not only is Marie severely malnourished, she has dozens of underlying/overlaying medical conditions, not to mention sores and raw spots on her tongue, inside her mouth, on her lips and corners of her mouth, that make it painful to eat or drink. Marie is 6 years going on 7 and is unable to stand by herself. She is dependent on her older sisters or mother to hold her and move her around. Even when they lay her on the ground to sit, she can’t sit more than 5 minutes before laying herself down.

Marie had been enrolled in the program for several weeks with no improvement in her condition, medical and nutrition-wise. She had received a diagnosis for TB months back at the government hospital so had been receiving treatment for that. This week, her caretaker reported poor appetite probably augmented by the open sores all over her tongue and in her mouth. The nurse directing OTP suggested we do a rapid HIV test.

The test is designed like a pregnancy test, or the rapid malaria test, Paracheck. You put a blood sample in the designated area, add a drop of buffer on top of the blood and wait 10-ish mins. The control is a positive control so you should see a line next to ‘CONTROL’ and hopefully no line on the patient side of the stick.
Marie was in her elder sister’s arms, her body limp, her head resting weightlessly on her sister’s chest. When the MCH-Aide came to poke her finger with a one-time-use lancet, the reactions were limited. She cried a barely-audible, whistle-like cry, and her big eyes choked up with tears. She had no energy to raise an arm in protest or turn her head to avoid looking. The HIV test got more than its required drop of blood, and the buffer was applied. I had been trained on reading the HIV test from the HIV/AIDS point person based in Masiaka so I knew what I didn’t want to see when I saw it. Was it the viral load or the blood volume, I don’t know. But what I hoped I wouldn’t see in the next 10-15 minutes, I saw before my eyes before 3 minutes had passed. What I didn’t want to see: two lines – one next to ‘CONTROL,’ on next to the patient blood sample. Marie was 6 years old and HIV-positive.

I looked up at the MCH-Aide administering the test. She looked back at me with weary eyes and said, “We’ll wait a few more minutes.” What she meant was, let’s wait the 10-15 minutes before reading the results, but of course, she and I both knew that 10 minutes later, the test wasn’t going to say anything different. I glanced back at the test stick – and as if to confirm this horrible thought, the red line of antigen-antibody-color complex showed itself, dark, saturated, clearly present.

I don’t know what emotions I felt when I read the results – all I remember is that my mind became flushed with a whiteness – a kind of numbness.

The nurse said she had only enough buffer to do about two more tests for the day – she would get more tomorrow. Talking to Marie’s older sister I was able to learn that the mother had born five children. Marie was the fourth. I suggested to the MCH-Aide that we invite Marie’s mother and the fifth child to get tested. Marie was 6, it couldn’t (shouldn’t) have been sexually transmitted – maybe it was through breastfeeding. Marie’s sister said that all the other children in the family were healthy. If all the other children were healthy and Marie wasn’t and was HIV-positive, it might be that the mother got HIV after she birthed the third child, before she had Marie. If this was true, Marie’s younger brother would have received the same infected breast-milk as she, which at least according to my logic made him a priority for testing. If Marie’s younger brother tested HIV-positive, we could start him on treatment right away. If only two tests could be conducted that day, I thought it should be the mother and Marie’s younger brother. The MCH-Aide agreed and sent Marie’s older sister to ‘send for’ them ‘quick.’

They all returned within 15 minutes. The MCH-Aide decided to first counsel the mother in private about the test, about HIV/AIDS and about Marie’s condition. The HIV tests were conducted on Marie’s mother and brother. To my relief and confusion, they both tested negative. Marie’s mother and the MCH-Aide interpreted the results together before the MCH-Aide left the room to notify her superior of the results. By then, Marie, who had been left to sit on the ground, had decided it was too hard to sit and decided to lie down. Marie’s mother looked out the window with an empty look for a few seconds, at Marie’s motionless body another few seconds then just burst into tears.

I froze. Red flags went up in my head, and I had absolutely no idea what to do. These women here don’t just burst into tears. Seriously, they don’t. They’re strong, resilient, aggressive, intimidating, and brave. The situation in front of me was something I could never have imagined. There was a mother of five in front of me, utterly vulnerable, what was I to do?

She was sitting in a chair holding her young son and I, behind her. I patted her shoulders from behind “Hush, hush, yeah? Your baby is going to get scared, yeah? Hush comra (suckling mother/mother in general), hush.” She then started to talk through her tears. This is what I was able to pick up:

“I tire, I tire!,” she’s tired, she starts. She went to the government hospital months ago because Marie was sick. When Marie was diagnosed with TB, they also did an HIV test on her, which came out positive. Marie’s mother was also tested and knew of her HIV-negative status. So it turns out she already knew what the tests today confirmed. They told her that they would do the TB treatment before the HIV/AIDS treatment so put Marie on TB meds, but Marie didn’t get better. The mother was tired that Marie was always sick, that she was never getting better. I think she realized after counseling today the role of HIV-positive status on Marie’s lack of progress in regaining health.

Talking with the MCH-Aide, I got more of the story. The mother was asked about needle-usage, blood transfusions… The mother told us about a blood transfusion Marie received three years back from a relative when she was seriously ill and needed a blood transfusion. A blood transfusion, in the 21st century, in a government-run hospital – and an HIV-positive 6-year old is the result? Seriously? Even if it’s an understaffed, under-equipped, hospital in a developing country, its in a African country where by default, they should be taking extra precautions to prevent the needless spread of HIV. Ridiculous.

To be fair, HIV could have been transmitted from other sources. Considering her patient history, she’s probably received countless injections for this sickness, for that fever- maybe one of those with a reused syringe.

Regardless, it doesn’t change the fact that the public health system of Sierra Leone failed Marie.

If this were the condition of your health care system, would you seek health care?

Poverty is most commonly cited as the primary barrier for seeking health care in SL. There is no doubt that lack of money keeps multitudes from seeking treatment from overcharging, corrupt, local health care providers, but there are other fundamental issues at hand.

Consider the history of the country, the people. The wound of the war is still fresh, and healing from something like that takes time. The war turned neighbor against neighbor, friend against friend, family against family. I wasn’t a part of it, so I can only imagine the horror. People here are re-learning how to trust other people, their neighbors, how to trust their government, how to trust health care. This process of learning how to trust and rely on others is one involving all peoples, not just those outside the government, but including those within it, including those overcharging, corrupt, health care providers.

This is a hurt nation, a healing people. If your health care system results in cases like Marie’s, you can’t fault people for not turning to government health facilities for treatment.

This government needs authority and the respect of its people, and it is the people who have the power (theoretically, and in some countries, in practice) to award that kind of legitimacy to a government that works to earn it. I guess they’re just going to have to work harder.


Marie.

Acknowledgments to Feia and Allan for engaging discussions on medical anthropology and Salone – thank you. More to come on health in Salone.

Traveling.

So I’ve been traveling all over the country taking care of business for the past month – forgive me for not updating.

Three weeks back I was in Sahn Village, Malen Chiefdom, Pujehun District. (Southern Salone) Two weeks back I was in Kono (Eastern Salone). Last week I was in Makeni (Northern, central Salone). This week I will be in Freetown (Western Salone). In two weeks, I will be in Seattle.

My Krio skills are such that I’m able to successfully take public transport (government bus, poda poda, taxi, motorbike) and find myself places to stay – alone. I tend to be risk-averse and unadventurous (despite your thoughts that I may be otherwise, I really am risk-averse), but traveling alone has empowered me with a sense of independence that I have decided to enjoy during my time here. Before I go back to the comforts of home.

Last summer when I was in Salone, I was mostly (save the motor bike commutes to the TFC during my stay in Makeni – see posts from last year) in the NGO vehicle. Doc, the national coordinator of the NGO I interned with last year, was out of the country for a little more than half the time I was here so I had the luxury of using the vehicle. Learning public transportation for me was more of a necessity this year. With one vehicle in the organization that breaks down and needs repairs twice every day (okay, maybe once every two days), with Doc being busy trying to coordinate things between Kono (Eastern Salone) and Freetown (Western SL), the vehicle has been pretty occupied. Besides, its not like I need it for clinic (a 5 minute walk from my “office”/living space) because we use the motorbike to transport our cartons of supplement.

Public transport is always daunting before you start using it. The Seattle-area Metro bus system was intimidating before I had to take it to the University of Washington campus for summer quarter, the summer before my senior year of high school. Yup, that was my first experience with public transportation – I’m not proud that it was so late – and it was great. Public transportation can be convenient (after you learn how to use it). Last year, I never seriously thought about learning how to take public transportation in Salone, but having learned the ins and outs this year, I think the system here works pretty great.

In most areas, there are motorbikes (read: motorcycles, I’m in Salone-vocab mode) that will take you short-ish distances (on average, 3-7/8/9-ish miles?) but it can go more. Bikes are great, but of course they’re dangerous (nobody ever thinks so though). The drivers never give you helmets and you ride usually with both hands on your lap. Chris and Katie have mastered this, but my right hand is usually on the metal bar/cargo rack thingie behind the seat and my left grabbing the coat of the driver (if the roads are rough) or on my lap (when I’m feeling comfortable) or waving to kids when they call out “WHITE MAN” lol. Bike-riding is cheap, convenient, exhilarating to say the least. I’ve also learned how to drive the bike, but don’t ask me to take you places. The last time I took Amadu out for a ride, with me driving, I almost ran into something (it was inanimate – don’t worry.)

Taxi’s in Freetown have a pre-determined route (5-ish miles) in the city that they’ll take passengers. Taxi’s in Town will ferry around 4-5 passengers. The long-distance taxi’s will go along the highway to major cities. Rides may take 1.5-5/6/7 hours. You can ask to be dropped off in between. These long-distance taxi’s are also sedans that will carry 7 (that’s the minimum number I’ve personally experienced) to 9 (my personal maximum) passengers. How is that possible? Oh, its possible. For example: 3 grown men + me in the back (without any ANY nudge room at all), 2 grown men in the front passenger seat, 1 grown woman (ALWAYS a woman because of a damned reason called gender inequality) with half her butt in the space between the passenger seat and the driver’s seat and the other half on the driver’s seat with her legs stuffed somewhere so it doesn’t interfere with the stick shift. The driver with ¾ of his butt on his seat, the other fourth on the door. I held a child in my lap, another child sitting on the lap of the two grown men on the front passenger side. – for a total of 10 people in the small car. Its ridiculously funny watching the car chug up small hills (‘I know I can, I know I can!’). No joke – a walking toddler would beat us up the hills we try to travel. I usually complain when the driver tries to overstuff the car “De driva e crazy! He de do anytin fo monie, nota so?” – it usually gets a good laugh of agreement from the passengers and the driver– so its not offensive.

Government buses are like greyhounds in America. Except for when they overstuff, its supposed to be pretty comfortable. The Gov’t buses go long distances and to major cities (Freetown to Kono, Freetown to Bo, etc). I am based in Masiaka (about 1.5-2 hrs outside Freetown) and wanted to get to Kono (Freetown to Kono is about 8 hours) but the bus was full by the time it got to Masiaka, but they were still able to take me. I sat on a deconstructed bus seat cushion on the floor of the bus with my feet on the front steps of the bus for the 6-hour ride. The view through the glass bus doors was amazing.


My bus to Kono - taken during a pit stop.


The view from where I sat.


non-ridic Poda poda - PATIENT DOG EAT FAT BONE - I think I get it.

Poda podas are van-size with 4 or 5 wooden benches in addition to the front drivers seat/passenger area. Because I’m white (through the window with technicalities, you’re either black or white here), I’m always offered a seat in what me and my friends have come to call ‘business class’ which is in the front either next to the driver ( and the annoying stick shift) or the front passenger seat. I honestly have never counted the load of a poda poda because I think it’s the most ridic of all public transport here. The area beneath the benches are stuffed with 5-gallon jerry cans of palm oil, 20kg sacks of rice, or bags of charcoal, and 10+ live ‘country fowl’ (read: chicken) so much so that all the passengers feet rest on the cargo underneath. There are probably 20-30 people inside the poda poda. The rest of the cargo (bags, more jerry cans of palm oil, more rice, more charcoal, live goat, etc) are tied on top of the poda poda. I’ve been cargo being tied up as high as the poda poda, itself, so that the total height of the poda poda+all its load = twice the height of poda poda with no load. There are usually young guys who are unable to pay full fare that ride on the outside, maybe two on average. They stand on the back bumper and hold the top of the car. Sometimes, they stand like that for 6-hour rides, and sometimes through the rain – ridic. Then we’ve got people top of the cargo on top of the poda poda. I can usually see their feet hanging down at about my eye-level when I’m sitting ‘business class.’

This Is Africa. ;)

여기는 시애라리온...

A note I sent to my mother - reposted for my Korean readers.

서부 아프리카 한 구석에 박혀져있는 작은나라.
노을이 눈부시게 짙고 아름다운 나라.
빈 깡통이나 돌, 막대기 장난감이 마냥 좋기만한 아이들이 있는곳.
1992 년 부터 2002 까지 내전에 휩사여 아직까지 상처가 많은나라.
망고와 파인애플 등 .. 맛있고 단 열매가 가장 풍부한 여름계절.. 추수 전 인지라 굶주림이 가장 심한 이 곳.
아직 수도인 프리타운에도 전기가 들어오는 날 보다는 안 들어오는 날이 더 많은 나라.
미국이나 한국에 몇십년 동안 없었던 말라리아가 일상인 사람들의 나라.
아프리카 나라 중에서도 제일로 가난한 나라.
태어나는 4명의 아이중 한 아이는 5번째 생일을 맞지 못한 채 죽는 이 나라.
그중 50%는 먹을 것이 없어.. 영양실조로 말라 죽는 곳.
현대인이 보기엔 머나먼 역사속 상황들이 눈앞에 그려지는 느낌이랄까요?
상상을 초월한 이 사람들의 현실…
고단하기만한 삶이 대대로 반복되고 끌이 보이지 않는 가난, 굶주림 속에서도 살아 갑니다.
날마다 뜨거운 태양빛 아래 밭을 매고,
앞이 보이지 않는 장마 속에서도 장사를 하는 이사람들을 보면서 생각한것은
아무리 없이 살아도 목숨의 중요함은 같다는것 말입니다.
이 사람들은 자신의 삶을 지키려고 일을하고,
이세상에 모든 부모처럼 자녀를 위한 꿈을 위해 살아갈 것 이라고…
그래서 부탁드립니다.
이 나라의 사람들에게 희망을 심어주는 기도를 해주세요.
하나님이 허락하신 인생… 아무리 힘들어도, 희망과 꿈을 품고 살아간다면
그들의 삶이 조금은 덜 힘들지 않을까요?
저의 안전과 건강을 위해 기도해 주시는 기도군단 여러분의 기도라면
주님께서 귀를 기울여 주실거라 믿거든요..
왜냐고요?
여러분에 기도제목과 같이… 제가 잘 있답니다!

걱정과 기도 항상 감사드립니다.
박아름 올림

Pictures: assortment.

Pikin Welbodi Program: Our Monday group, waiting for clinic to begin.

Pikin Welbodi: This is how we get our RUTF from our office to the clinic. Unsafe, I know, but Amadu goes "small, small" for the 1-minute ride to the clinic.

Pikin Welbodi: Mass taste test. Yum. Groundnut merecin. ^^

Pikin Welbodi: A boy pikin in the program. I often have trouble remembering each kid we treat, but this one sticks out to me. Not only because he's on the sicker side but also because its his aunt that brings him. His mother died when he was just a few months old. The aunt that brings him has a nursing baby and was wanting to get back to her own child the first week, so I was a bit worried about him continuing to come to the program. I was encouraged and thankful that she brought him this week for the second week of treatment. Yay!

Pikin Welbodi: I also remember this one because I MUAC-screened her and referred her to the program. This one is fussy when we get her weight and length. lol.

Pikin Welbodi: Mother and her 2 pikin (see the one on her back?). Just watching us do our work. ^^

Pikin Welbodi: A father gives his thumbprint of approval on the informed consent form for his child's participation in the program.

Pikin Welbodi: As soon as we distributed the RUTF, the kid wanted it so badly! Yes! A good sign. Its an indicator that she recognizes the RUTF (so she's actually getting it at home) and that she likes it. This kid also increased in weight this week. When I looked at her chart and said "Increase!" The mother said "INCREASE!" with a huge smile and started dancing. She knew that it meant her child was getting better.

Pikin Welbodi: The last pikin to leave Tuesday clinic this week. Waiting to be wrapped on her mother's back, it seems like she saying 'gimme.' What a cutie.

Life in Masiaka: The well being dug next to the office. It was hand-dug. Yes, all of it. TIA - "This Is Africa," as so many people here often say. The workers lower down a course cement for the guy in the well to construct the walls of the well.

Life in Masiaka: Dinner. Bread is 500 Leones and a can of imported baked beans is Le3500. The exchange rate is $1 = Le3200. Dollar Menu from a new perspective.

Life in Masiaka: I would eat this any day. Pineapple so sweet, so ripe that you can eat it to the core. There's nothing to waste. Price of pineapple varies depending on size. Big, juicy ones usually Le5000 but people who like me just give them to me ^^

Life in Masiaka: What the kids in the neighborhood do to impress me. Leaf (finger)bags! Big enough to ornament your finger. I know how to make them now - really easy. No glue, no tape, just one leaf!

Life in Masiaka: Auntie Fanta's shop next to Bo Road at the Maskiaka Junction (which is like "Downtown" Masiaka - a 5 minute walk from the office)is the best place in all of Masiaka to get cold drinks. I get everything from there: my water, col' soft (cold pop), beans, toilet paper, laundry soap, face soap, mayo - everything. So its a popular pit stop for people traveling towards Bo (second largest city in SL). I was here one day when I met Aminata and her mother. I was drinking my Sprite when I saw the little kid and recognized her puffy, edemacious (sp?) face. I asked to see her feet and observed her belly. Her feet had pitting edema and her abdomen was also swollen. Aminata wasn't malnourished - there are tons of other medical conditions that will illicit edema and it was really frustrating that I had no clue what. She and her mother were going to Bo (where Aminata's father works) to get Aminata treatment. She and her mother live in Portloko, but all they did was give her treatment for malaria. This kid obviously had more than malaria. MSF (Doctor's Without Borders) has a great facility in Bo focused on maternal and child health. Hopefully they'll get good, quality care there.

Motherhood.

“Motherhood is not supposed to be a death sentence.”
I remember reading it somewhere – I want to attribute it to an article from Nicholas Kristof’s NYTimes column, but I can’t be sure and my internet connection is too slow for me to go find the correct citation for you.

“According to the United Nations, a woman’s chance of dying in childbirth in the United States is 1 in 4,800. In Ireland, which has the best rate in the world, it is 1 in 48,000. In Sierra Leone, it is 1 in 8.”
This one from http://www.washingtonpost.com/wp-dyn/content/article/2008/10/11/AR2008101102165.html?hpid=artslot&sid=ST2008101201887

On Monday afternoon, I helped in the delivery of a baby boy. The woman in labor, Fatmata, was 23, just two years older than me, and this was her second child.
The MCH Aide (Maternal-Child Health Aides are Nurse Aides) trained in midwifery was directing the delivery. I thought I was just observing until she said “Ah, so you are going to receive the baby for me today!” and handed me a pair of examination gloves.

“Uhh.. umm.. I, uhh, don’t know anything about delivering babies!” I said, half-panicked by the confirmation in her voice that I was actually to “receive” the child – whatever that meant. “All you have to do is, when the head comes out, you turn it like this and pull it down and then up, like this!“ She put her hands on my ears, pulled it down, rotated it a little, then pulled it back up. The point, she said, is to guide the shoulders out. I told her politely that I’d just watch.
We entered the delivery room. It was small, cramped, smelled of sweat, bodily fluids, and dirt – or dirtiness of the musk of old medical equipment, “cleaned” and to be used in this birth. It was about 1 in the afternoon, but the room was only dimly lit by the sunlight coming through the window in the adjacent room. No electricity means no light, no nothing, so the MCH Aide was using a battery-powered LED headlamp to do her work.

In the adjacent room were 4 women: Fatmata’s mother, her sister-in-law, mother-in-law, and the TBA – traditional birth attendant of their village. It was a pleasant surprise to see the TBA at the clinic, helping with the birth. The incompetency of TBAs is commonly cited as an aggravator of maternal death statistics in the country. Health professionals complain that they often receive cases too late from TBAs to do anything helpful for the mother and/or baby. Families often choose to have babies under the assistance of TBAs mainly because of the birthing fee at the hospital or clinic compared to what they’d have to pay, or not, the TBA. Distance and logistics of getting to the clinic are also probably factors that hinder births in clinics. As of late, the MoH has been more active about promoting giving birth at clinics. Locally, they enforce this policy by leaders of communities levying fines on TBAs who don’t refer cases to the clinic and fathers who oppose going to the clinic (because of the birthing fee).

Two hours into labor, Fatmata had barely made any noises. Some squeaks, some complaints of pain, and a few quiet moans when the contractions came, but no screaming, no crying. Two senior nurses (“sisters”) working at the District governmental hospital joined us at that time. They were making their rounds, monitoring Phase II of the Polio campaign and decided to observe the delivery.
During the third and into the fourth hour of labor, the MCH Aide drained Fatmata’s bladder, took her blood pressure, monitored the timing of the contractions, and the fetal heart rate (with an extremely crude-looking instrument which she called the ‘fetal stethoscope’), administered an oxytocin drip, among other things. I was going in and out of the room, half because I wanted fresh air, half because I was looking at the patient chart. Okay, mostly because I wanted fresh air.

The women waiting outside asked me if I had “born” any pikin – and looked amused/surprised when I said I hadn’t. Then, I heard a quick shuffling of feet – a change in pace of the sounds I was used to hearing from the room. Fatmata’s water had broken.

About a little more than half an hour later the baby started crowning. We saw the head coming out, and then it stayed there for a good while. Then after what seemed like forever, the head came out. After some difficulty rotating the baby so that it could be positioned for the shoulders to come out, it sort of turned itself (one of the sisters commented: “So you see, that is God’s good work.” – referring to the baby turning itself). Then it stayed there. The baby, with its head peeking out into the world, didn’t want the rest of its body to come out – or maybe Fatmata was too tired of pushing. The MCH Aide pushed her fingers here and there trying to guide the baby’s shoulder’s out, but with no success. Looking at the size of the baby’s head, the nurses were commenting in the back of the room how big the baby was. The rest of the delivery wasn’t going to be easy.

I stood there for a few minutes just looking at the head of the baby. Then its mouth started twitching. Seeing this, the MCH Aide told Fatmata: “The baby wants to breathe! You HAVE TO PUSH!” A few long seconds later, I felt the tension in the room escalate. I felt something wasn’t right – the senior nurses started to raise their voices, urging the MCH Aide to try this, push there, look for that – but to no avail. The rushing of the senior nurses to put on gloves and join in the delivery confirmed the feeling in the pit of my stomach. One senior nurse held Fatmata’s head, held her left hand and started encouraging her to push. The other nurse started pushing and prodding Fatmata’s belly while the MCH Aide continued trying to find the baby’s shoulders.

The next segment of the delivery was chaotic and I’m sure it was short, but I remember it most vividly. Fatmata’s mother, who has been silent and stone-faced since the beginning of the delivery starts crying – something must really not be right, the baby probably isn’t supposed to have just its head out like that for so long. A few more long seconds pass, the struggle continues. My stomach is in knots and I want to cry, but I find myself joining in the “Come on! Push! Baby’s almost HERE FATMATA! PUSH!” Then I see a little bit of blood – something in Fatmata must have ripped. Shit. Not a good sign. Then I remember the maternal death statistic: One in every eight. I’m thinking all sorts of things now: ‘If the bleeding is serious, she’ll need a transfusion, but there’s no blood bank (with accompanying thoughts cursing the fact that there’s no electricity), so I wonder if anybody in her family will be willing to donate, will my blood match hers?, will her family allow her to take my blood?, but wait there is probably no apparatus to clean/test/whatever my blood before they do the transfusion, or maybe they don’t need to…’ and then I justify to myself why nothing can go wrong with this delivery: ‘because she’s young – 23! For God’s sake. Because there are two senior nurses overseeing the delivery with the MCH Aide, because the TBA is also here helping out, because they brought her here early as soon as she went into labor, because shes received pre-natal care, because she’s already worked so hard and come this far, because I’m here (last item is questionable, but it was a passing thought) and she just can’t die.

So my mouth is yelling stuff Fatmata probably can’t really understand, my mind is running off with thoughts of its own, but then I see a shoulder, then another, then the rest of the kid comes rushing out with all the accompanying fluid and stuff. Yes, stuff. It’s a boy.

The MCH Aide grabs the clamp and clamps the umbilical cord and cuts it, the one nurse is busying trying to take fluid out of the kid’s nose and mouth, the other is taking care of the mother side of things, and the MCH Aide rushes to help her. The delivery is finished, but something still isn’t right – isn’t the baby supposed to cry? Where were the shrill cries of a baby’s first breath? I hate this eerie quiet – its not supposed to be like this, is it? Again, panic. And this time, I really want to cry.

A senior nurses asks me to carry the baby into the adjacent room so we can work on him. I wrap him up in a lappa and carry him outside the birthing room. He’s got a blue-ish tint to his face – not a comfortable color. We want the nice red color of oxygen-carrying hemes. She starts resuscitating him with gentle, fast-paced movements of her fingers. I continue the massage while she clears more fluid from his mouth and nose. She grabs his feet, turns him upside down and beats his feet a good few times and alternates that with furious back-rubs. ‘Come on, come on! Breathe, little guy. Please? Come on..’ I’m super scared now, my eyes are watery and my nose is running. She puts him back down and continues to clear fluid while I continue the heart massage. The nurse pinches his nose and that does the trick. As if he’s super annoyed, he gives a weak cry. YES. Like he’s eaten a drop of red food coloring, his body flushes into a pale pink color. So he’s okay for now.
The TBA and MCH Aide clean up after the delivery and Fatmata has been moved to a cleaner bed. The MCH Aide says “You will tie the cord, ya?”
“I don’t know how to tie the cord.”
“No problem, you will do it.”
‘What do you mean ‘I will do it’?! I’m telling you, I have no idea what it means to tie the cord!?’ I’m thinking, utterly frustrated that she doesn’t understand my incompetence while she cuts a piece of string that looks like what they use on cooking shows to tie big rolls of meat to keep its shape while cooking. Butcher’s string? Its called something like that.
But I find out that ‘tying the cord’ doesn’t require lots of expertise: I do an extra tight triple-tie about an inch below the clamp still holding the umbilical cord. “Tie is tightly so he don’ bleed” she tells me as I do another extra-tight triple tie right below the clamp, which she then releases. “So that’s it?” “Yes. We will keep like this until the rest falls off with time.” The MCH Aide motions for me to take the baby and follow her. We go into the lobby of the clinic to where she brings out a scale. She balances it and I confirm the reading for her: 4.8 whopping kg’s. That’s one big child.

I bring the child back to where is mother is resting. I do the thing that nurses working the nursery do where they present the newborn to the rest of the family through the glass window “Fatmata, dis na you boy pikin! Na you born dis one!” I’m a little upset by how disinterested Fatmata is in her newborn – she barely looks at him. She must be tired, I understand. “Dis pikin get nem?” “No sabi” I don’t know. is the response one of the women give with a sheepish smile. No duh, I feel a little foolish – the Temne people have naming ceremonies a few months after birth. Trying to be baby-friendly, I lay the boy next to her breast and encourage her to hold her baby to start suckling. It’s probably nearing an hour since birth and I’m thinking it would be nice to see the baby take the breast. “Gi ‘em di bobi,ya? It’ll also help your uterus contract…” I look to the nurses to help translate this last bit. I think she understands what I’m trying to get her to do, but really, she’s utterly disinterested – in breastfeeding, in the baby. I take her hand and try to get her to at least touch her child, to hold him because she hasn’t yet done that. Seeing that I’m having no success, a nurse comes over to help. She nudges the child closer to his mother and takes one breast and offers it to the mouth of the baby. The baby gives an annoyed cry and contracts muscles in his arms as if in defiance. She encourages the mother to keep trying. “When the pikin yawns and opens his mouth, you just give him breast,” she suggests. 15 minutes into trying to get the kid to suckle with no success. The MCH Aide says that he’s tired and angry. That, and Fatmata looks unmotivated. The chaos of the delivery has completely subsided and the nurses say their good-byes. The MCH Aide is looking over the paperwork when a tall, thin, regal-looking elderly-ish man enters the room, then I know the time has come for the money discussion to begin.

I think I should probably leave now, but my curiosity holds me back for a little bit: will the MCH Aide ask for a special tip? Will she overcharge? How much does it actually cost to give birth in a clinic? The man in the room looks old enough to be Fatmata’s father, but then again, I’ve learned that you really can’t assume anything – he could be the father of the baby, so I decide to ask cautiously. The MCH Aide, also unable to make the distinction, asks the man. He’s the “father of the father of the baby” – so Fatmata’s father-in-law. He starts his monologue with a sigh. I’m able to pick up that he is asking the MCH Aide to write a letter which he wants to send to his brother for money to pay the birthing fee because he has nothing and how he needs the letter because his brother won’t believe his word... The MCH Aide asks about Fatmata’s husband. He’s left her. Certainly, he’s sent his pregnant wife something? She asks. “Nah, notin,” the father-in-law replies, looking down. There’s an awkward silence while I’m thinking maybe its because of Fatmata’s abandonment that she looks so disinterested in her child. She’s 23, and she just delivered the baby of a man that’s left her. To avoid putting myself in an awkward position where I would be asked for money, I decide its time to excuse myself. I get confirmation that Fatmata’s tearing is external (“She won’t even need sutures”) and remind Fatmata that she should try really hard to suckle the baby soon and to “Gi ‘em only di bobi fo 6 mons, ya? Di bobi get all di pikin wan’ for gro.” I give the abridged version of my 6-month exclusive breastfeeding schpeel then quietly excuse myself and let the conversation run its course. A conversation that has probably repeated itself in that room many many times before. Money. ugh.

I don't know what the future holds for Fatmata and her boy. But for now, I am thankful that both are alive and well.

A baby boy. All 10 fingers, all 10 tosies. Pink and breathing. 4.8 kg. Wow. Imagine that.