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.

Fathers.

The thing about programs targeting women and children is that they do just that – work with women and children. Often times, that can be a barrier to achieving the goals in development and health that NGOs and ministries of health so desire. Birth spacing, family planning, effective breastfeeding even (yes! breastfeeding. There is a taboo here that breast milk becomes dirty and unfit for feeding to the baby after the mother engages in sexual intercourse so the mother will stop breastfeeding prematurely) cannot be done with the will and choice of women alone. For a lot of these initiatives you need to try to involve the men, the husbands, the fathers.

If you call a bunch of women and tell them that they should have only the number of children they can financially support, and that there are family planning options for them – you are putting the burden upon the women to go back to their households to explain, convince, and get the permission of their husbands to do what health administrators advise. This is easier said than done – its not hard to see why women practice birth control without their husbands knowing. Husbands often reject birth control methods because they worry about the infidelity of their wives. Islam allows men to take up to 4 wives, but of course, the women must accept that and live faithfully. Ho-hum.

Before the rant, I wanted to say: That’s why its so encouraging to see fathers at the clinic. I love it when I see fathers at the clinic because it tells me that they care, that they support the treatment of their child, and because it shows me that they don’t delegate childcare as a woman-only duty. I saw three fathers this week: one who brought his child in alone, and two who came with their wives and child.

One couple came in with twins. With these outpatient programs giving supplements, its protocol to enroll both twins, even if one is not necessarily malnourished because you assume the sharing of food (more so than with other siblings), especially because they are twins. The mother and father each carried a twin while waiting for registration, during registration, and throughout the taste test. Observing them left me with that warm, fuzzy feeling. :)


June 21 was fathers day.
Unfortunately for my dad, neither of his two daughters was home to give him the hugs and kisses, the thanks and appreciation he so deserves.
My younger sister, Joanna is off all the way across the country at hardcore music camp and I’m halfway across the globe. But he was okay with it. “I’m happy if my daughters are happy,” he said – like always.
Thanks Daddy. ^^

My Dad, making sure, as always, that I'm well fed! heehee
Love you!~

Step 3: Pikin Welbodi Program...

So step 2 is to be screened, which means to get your weight and height measured. If a pikin fits the criteria for moderate/severe malnutrition without medical complications or edema, we can enroll the pikin into the program.

At the clinic:
Station 1: Get measurements taken (length, weight, MUAC, check for edema), receive registration card and patient chart. This can be a dangerous job! Amadu, who is in charge of getting the pikin length gets peed on at least thrice a day!


With their cards and charts - waiting for registration.

Station 2: Interview with nurse. Nurse obtains informed consent, caretaker signs or fingerprints, nurse gets patient history.

Nurse Andrew interviews a caretaker.

Station 3: Taste test and training on how to use RUTF. Distribution of RUTF! – My favorite part of the day.

RUTF taste test and instruction on proper use. Isata and Amadu instruct caretakers on how to feed their pikin 'groundnut merecin'


Isatu giving special one-on-one instruction to a mother.

Play station, a safe space for children: For siblings of the patient that the mother may bring. We’ve got paper and crayons, stuffed animals, jump ropes and a couple deflated balloons (so they don’t pop easily and so they’ll make less noise when they do pop). This station was created as part of an initiative to encourage weekly attendance – by making the clinic more attractive in other ways (to other children, for example, so it takes the stress off the mother to look after the patient and the other child while she’s getting advice from our nurses).

:)

What I love seeing:

...when pikin like eating RUTF - this pikin (who was the cutest thing in a dress made to match her mother's dress!) was sucking her spoon on her way out. Loves it! ^^

Thank you everybody for your encouragement, good thoughts, and prayers.

Next week, we'll split the mothers into two groups of about 15 and have discussion on the topic of 'breastfeeding' facilitated by our nurses before we start clinic. We brainstormed key points and taboos to address. Keep us in your thoughts!

Status of Active Case Finding: complete (for now.)

With the coverage of 4 more villages on Wednesday, we’ve finished Step 1: Active case finding. Here is the summary:
Villages covered: 8 (Masiaka (a relatively large town) + 7 peripheral villages)
Children (under 5 years (U5)) MUAC-screened: 734
Children referred to Pikin Welbodi Program for screening: 113

Here is the summary of the first week of the Pikin Welbodi Program:
Children screened: 99
Children enrolled: 44
Children referred for inpatient treatment: 4

So we referred 80 children from the Masiaka town to come to the program to be screened on Monday. 60 of those 80 showed up (a decent turnout rate) to be screened. 25 more children showed up to be screened without referrals. So on Monday we screened 85 children and enrolled 35 of those pikin.

We referred 13 children from 3 peripheral villages to come to the program to be screened on Tuesday. 12 of the 13 showed up (a great turnout rate) to be screened. With 2 more children showing up without referrals, we screened a total of 14 pikin. We enrolled 9 and referred 2 for inpatient treatment.

If you’ve paid attention to the numbers, you would have noticed something interesting:

Monday: 85 pikin screened from Masiaka, 35 enrolled, 2 referred.
Tuesday: 14 pikin screened from villages, 9 enrolled, 2 referred

Masiaka town is pretty “urban” compared to the more “rural” villages on the periphery of town. I feel like what I’ve been reading in literature – about how malnutrition hits those living in rural areas the hardest – is coming to life in front of my eyes. On Tuesday, when we screened the pikin we had referred from the villages, we determined most of the of the children we screened to be acutely malnourished.

On Wednesday, we MUAC-screened under-fives in 4 more villages and referred 20 to the clinic next week – I’m afraid of what I’ll see then.

On another note – we have had mothers actually come to our office with their malnourished children! These are children that we miss during our door-to-door active case finding because they are in the fields with their parents. This is a good thing that mothers are actively seeking our program’s help (not a good thing that we have lots of malnourished pikin) because that means they are hearing good things about us from their neighbors. Yea!

Step 1: Active case-finding

Visual aid outlining the program - used for orientation of program staff.

So the first step in the idealized CMAM (community management of acute malnutrition) program is active case finding. We did this with 5.5 (I am the half, because I took pictures half the time) people, covering 4 villages, going door-to-door, in 3 days and MUAC (mid-upper-arm circumference)-screening 613 children under 5 years of age. Of the 613 children we saw, we referred 93 with "dangerous" MUACs to the Masiaka Clinic for screening (weight an length).


Active case-finding: Andrew, James, Isata, Isatu, Amadu, 0.5 (taking the picture)

80 of the 93 we asked to come on Monday, June 22 and 13 of the 93 we asked to come on Tuesday, June 23.

Yesterday, June 22, we screened 85 children, 60 of which were from active case-finding referrals, 25 who came having heard of the program from word-of-mouth (word gets around really, really quickly). We enrolled 35 children (!!) and referred 2 children to the Makeni Therapeutic Feeding Center for inpatient treatment due to the severity of their cases.

Children who were enrolled took home RUTF (ready-to-use therapeutic food, which in our case is locally-produced Plumpy'nut - more about that in another post!) and those who came for screening but were not enrolled, we gave a bar of soap so that their walk to the clinic was not in vain.

Though we've asked only 13 children to come today, the nurses Andrew and James were telling me yesterday that we will probably see as many children today as yesterday because word has gotten out about our program... we'll see - and I'll tell you more about it later!