Babycatcher

This is the blog of my dear friend Stabliy Msiska. She is the charge nurse in the labor ward at Bottom hospital. A dear friend who is an obstetrician living in Norway set up an exchange program for Norwegian obstetricians and midwives to come to Malawi and Malawian midwives to go to Norway. Stabily is the first Malawian to go to Norway. She was not previously a world traveller. I think those of you who have been reading my blog will appreciate a glimpse into the reverse experience. http://www.stabilymsiskablogger.blogspot.com/

I finished my rotation, at last at Konfo Anokye Teaching Hospital. My Obstretrics and Gyenecology rotation was the final component. I had been looking forward to again being around birthing mothers and newborn babies but in the end I don’t think I can tolerate being witnessing this type of birth much longer.

I am yearning to work in an environment like Holy Family Birth Center. When I was young my mother would occasionally take us to Weslaco to visit a friend of hers who she met in Bolivia years earlier. As a child I did not place any importance on the words “birth center.” When Sister Janice and Sister Angela talked to my mom about their work I listened and let it go. For me it was simply a peaceful stopping point near the Gulf or on our way to Mexico with open flat land, goats and chickens, and many friendly women.

The summer after I qualified as a registered nurse, before my midwifery training, I went back with new eyes. I spent a couple weeks at the birth center volunteering (observing). Sister Angela founded the birth center in the early 80s to serve women who had nowhere else to go – poor uninsured women and illegal immigrant women. She not only gave them a place to deliver but provided excellent care throughout their pregnancy and postnatal period. The grounds include a small clinic, basic housing for the few staff midwives and volunteer nurses, a small chapel, space for chickens and goats, and five free standing suites for deliveries. Each birth suite contains a double bed, a rocking chair, a couple stools, a counter and sink, a bathroom and a small kitchen.

During my three weeks there I witnessed a handful of births. Each was beautiful, peaceful, personal. I loved the births but I also loved that an hour or so after delivery the midwife would wrap the baby’s body and wash his head under running warm water at the sink. The babies would never cry; they would close their eyes and move their heads in a rocking motion clearly enjoying the warm water and gentle massaging touch of the midwife. I loved that after the birth, when the woman was lying comfortably with her family and newborn in the double bed, the midwife or nurse would ask them what they would like to eat and then go to the kitchen and prepare the food herself. I loved that the nurses would visit the women in their homes or trailers for their postnatal checks. I loved that the quality of care given was what we generally believe accessible only to the wealthy but there was given compassionately and lovingly to the poor. And for the babies, their gentle welcome was an appropriate end to their difficult journey and a promise that the world is capable of offering comfort and love.

The births I have witnessed more frequently stand in dramatic contrast to those at Holy Family in Weslaco, Texas. Women are treated as though every cry of pain and every gesture of reaching out to touch a clinician is a personal affront to the nurses and doctors. I can’t understand the language here but I can certainly understand the tone and I do understand “mepakyew” which I hear the women say over and over to whoever yells at them. Mepakyew means please, or to be sorry, or to beg and the literal translation is “I lie at your feet.” No one rubs backs or holds hands; the only touch is the clinical touch. I watched a doctor give a woman a “gentle” slap on the thigh to tell her to spread her legs. I have seen few give a warning before beginning a vaginal exam or give an explanation afterwards. I have seen many give a harsh look or word if she cries during the exam or pulls away. I have seen newborn babies held without tenderness , picked up by two arms or just one, held by the back without supporting the head, placed on a sheet covering a cool metal table, suctioned vigorously so they gag again and again even if they come out pink and crying. I was horrified to see a few newborns scream as they were bathed in cold water (this was not at KATH and not done by nurses and I did inform the charge nurse that it was happening). On one hand after my couple days in the KATH labor ward I appreciated how much change occurred at Bottom during my three year stay, thanks I believe in great part to Dr. Meguid and a handful of motivated clinicians who were also eager to see change. On the other hand I feel so tired and sad. I cannot watch this anymore. I want to provide an alternative not just a hand to hold or a kind look to help make the inhumane treatment a little more bearable. It should not be born.

The morning of my second day in the labor ward at KATH I met Ama. Ama was struggling with a premature urge to push meaning that well before her cervix was completely dilated she desperately wanted to push her baby out. Usually this happens when the baby’s head is very low in the pelvis during early labor. The danger is that if she pushes against a partially closed cervix the cervix will swell, it will not dilate well and may become an obstruction or may tear, generally the mother tires early and her baby may show signs of excessive stress. During the contractions Ama would cry out and push, the vessels in her neck protruding as she strained. Periodically the nurses and doctors would yell at her from across the room and she would tearfully say over and over, “mepakyew”. I stayed with her. I rubbed her back and encouraged her to try different positions that might alleviate the urge. The urge was still strong but she cried out less while I was with her and every now and then she would look intensely into my eyes and say, “God bless you.” When her cervix was finally 9 centimeters I led her to the delivery bed and as she pushed I held pressure on her cervix and soon felt it slip over the baby’s head. I stood so that I blocked the nurse’s view of her perineum and no one yelled at her to push. She did an amazing job. She focused and pushed with each wave of contraction and released and relaxed complete when they passed. I encouraged her to continue following the rhythm of her body and the baby’s head crowned slowly. Luckily the resuscitare was occupied by another baby so I wrapped her newborn and placed him in her arms. She had no tear so I cleaned her and led her back to the bed then helped her breastfeed. The rest of the day anytime I looked in her direction she said, “God bless you. May God really bless you.” At one point she even tried to give me a handful of money. I received so many blessings from Ama that day. It felt great to help her but sadly what I did was nothing beyond basic care and her effusive gratitude was simply because the treatment she received before I stood next to her was really not care at all.

A few times during my three months at KATH while chatting with house officers (the equivalent of American first year interns) they asked me what I enjoyed about being a midwife and said that they really did not like O&G. Now I certainly understand why. If this is the sum total of your experience regarding birth - such an ugly side with only messiness, pain, yelling, and a policing attitude - it would be difficult to imagine beauty. There is a great potential for beauty. While I was on the labor ward, the house officers were often much more gentle than their seniors and I realized that the treatment of the women though most painful to the women themselves, also hurts all who stand by, slowly killing the voice that says quietly, “this is not right.”

Now that I have finished I am supposed to go to Accra to turn in my signed form from the hospital and pay another US$200 to register. I will actually be flying to the States on Sunday for a few months to work and be with family and since Clement will soon be heading to Malawi this is our last week together for some time. I am already dreading our separation. There is a Philippina nurse who became my friend during the rotations who will also be heading to Accra for the same purpose and she offered to take my papers so I could spend a few more days with Clement (and leave on Saturday instead of Thursday). I called the Nurses and Midwives Council to explain my situation and ask if she could hand mine in and whether I could sign the necessary papers on my return. The response I received was, “You need to set your priorities, everyone has husbands and children but if you want to practice as a nurse then you need to follow the rules here. . . Why can’t you come to Accra a day early to turn in your paperwork?!!. . . Maybe you should just stay at home with your husband if that is your priority rather than work as a nurse . . . “ She went on and on for a while chastising me for the effort I was creating for other people. Finally I interrupted and said, “I understand that everyone has husbands and children and that is why I thought you might understand. I am sorry that I am creating so much trouble for you. I am sorry I asked. Please forget it. I will come in person. Have a nice day.” Then I hung up on her. Then I cried (I am really too sensitive). Then I realized that I had just received a small taste of the attitude women in labor here face, which made me feel somehow better and worse.

Our work is going on and we are trying to apply for grants but in the meantime we are surviving hand-to-mouth. If you would like to find out about what we are doing or donate (any little bit helps), here are a couple links . . .

A radio interview I did that aired in March about our work in Malawi: http://www.worldvisionreport.org/Stories/Week-of-March-14-2009/Midwife-in-Malawi

Our website if you are interested in donating: www.africanmothers.org

Thank you for your donations, your encouragement and kind words, and your simple willingness to follow the stories here.

I am now coming to the end of my general nursing rotation at KATH. Monday I will start Obstetrics and Gynecology and then I will be through. Everyday has brought its own stories here are some along the spectrum of good and bad.

A young teenager with cancer had his right arm amputated. He is one of the few boys in the men’s orthopedic ward. The ward is full of men with broken legs and arms from car accidents. They spend months in ward, waiting for bones and wounds to heal. He is the only oncology patient here. His wound is rank and large and he cries out each time I dab the gauze in an attempt to clean it. He forgives me the torture I inflict and afterwards we chat. When I leave the ward I still return to chat. I ask him about the wound, he says it no longer smells and the pain is decreasing. Every day he reads two newspapers. His brother brings them every morning. He lies in bed on his back, an ankle crossed over his knee and flips through the paper with his left hand. I ask him what interesting stories they contain and he tells me about a lion terrorizing a village. He says the paper included entries about the lion and the chief who fought him by hand for three consecutive days. He says the chief was working in the field when attacked, that he was badly injured and arrived at the hospital with wounds all over his body. He points to the picture of the chief lying in his hospital bed smiling, his left arm amputated and bandaged. He says the chief said he was grateful to have his arm amputated because the pain was too much. Then he flashes me his own beautiful smile.

A man tells me he would rather die than undergo a life saving surgery that would leave him impotent. He says he would surely become an alcoholic, saying that he would turn to alcohol unable to live haunted by the fear that his wife might be sleeping with another man. Instead he is willing to die and leave her with their three young children.

The day we change dressings in the orthopedic ward I change the dressing of a man with a bad avulsion injury and fracture with pins in his lower leg. The patients in the beds around him smile and tease him saying that he will sleep well because I changed his dressing. They all ask me to change their dressings the following day. When I arrive in the morning they greet me warmly and even those I haven’t said a word to all day smile and wave goodbye at the end of the day.

I spent three days in the burn unit. There were few patients but their burns were severe. There were three children: an infant disfigured by a fire, another infant who fell into a basin of boiling water, and a child who was splashed with boiling oil. There were two young women with acid burns, both had the acid thrown on them by jealous x-boyfriends. One cried silently throughout the day, the other hid her disfigured face from the patients around her.

In one ward there is an epileptic man, who while cooking had a seizure and fell into the fire. He sustained third degree burns over one arm and half his torso. By the time I arrive, he has been on the ward for a month. He sits quiet and motionless all day perched on the edge of a chair holding his neck and arms in stiff awkward positions which cause the least amount of pain. On the day his dressing is scheduled to be changed I ask the nurse about pre-medicating with pain medications before the dressing change but she says that patients here can tolerate pain better than where I come from. I suggest that perhaps they only tolerate it only because they are given no other option. He screams as they remove the layers of gauze. As they remove the dressings maggots fall on the floor. The nurses try to hide their disgust, some better than others. His wounds smell sweet and foul and the skin is rotting on his body. The nurses say to me, “Don’t worry the doctor will look at his wounds today and decide if he needs surgical debridement.” I leave the ward for lunch and return to find him in the middle of the floor twitching with rigors and people stepping over him. The nurse says his seizure began just after I left (just after his dressing change was complete). They say, “Don’t worry his doctor is here and will see him. I go and stand over him they ask me, “What do you want us to do? Carry him to his bed?” Feeling tears welling in my eyes I say, “Well?” and “How about a sedative to calm his twitching?” They watch me watching him and come to help me lift him on to his mattress. The doctor writes an order for a sedative. His doctor finishes rounding on the other patients , he does not look at the man still shaking on his mattress, he writes an order to use honey on his dressings, and leaves the ward. I ask the nurse whether the doctor will look at his wounds and she says, “Don’t worry he will come back tomorrow or Friday.” Later I see a nurse pocketing this patient’s medication. The next day I check his medication, the pills are still missing. The patient will be billed. He does not have insurance. The doctor does not return that day.

In the pediatric wards there is no room for the mothers to lie down. The mothers and a few fathers sit on wooden stools at the side of beds and during the night they just rest their heads on the mattresses to sleep. A parent must always be present so some parents spend months sitting on stools. Occasionally a small child is assigned alone to a twin sized bed (most beds have two children on them) so these parents can share the bed with their child at night.

A six year old boy comes in with a cough. From the x-ray it appears his has pleural effusion. He is sent to a regular pediatric ward, after a few days a chest tube is placed but little fluid is drained. The lung does not improve but the boy looks well, sitting on his bed tethered by the chest tube, talking, laughing, blowing balloons to exercise his lungs. Samples are taken from the drainage and sent to the lab to isolate the offending organism. The results are not returned or are lost, the infection does not respond to the antibiotics, during rounds the attending pediatrician says it is most likely tuberculosis. A test is done for tuberculosis but the results again do not make their way to his chart. TB meds are not started, instead they decide to open his chest. I leave him in the ward. Several days later I begin my rotation in the ICU. A critically ill boy lies unconscious on the first bed. After some time I recognize him. The surgeon says his lungs were filled with pus. No sample was sent to the lab. He never regained consciousness after the surgery. Three days later he dies. His mother brought him in with a cough, spent three months sitting next to him in the ward, and will leave with his inert body.

I come into the pediatric ward and move bed by bed through the room. Fifteen feet from the nurses desk I come to a severely malnourished young boy. His condition was very poor when he arrived, he is extremely wasted and his belly is hugely distended. He lies bundled in a blanket and his pregnant mother sits on the stool by his side. I look at his chest and see no movement. I listen to his chest and hear nothing. I touch his face, he is already cool; the life passed out some time before. I hear another mother behind me sighing, understanding - before his own mother - what has happened. I tell the nurses and the doctors. They briefly examine him but say nothing to the mother. I put my hand on her shoulder. She starts to cry but then stops herself. I take her into another room and ask a student nurse to interpret. We talk and then, after they remove the body, she lies on the floor in the quiet room. She must stay until the bill is paid.

In a quiet side ward with two beds there is a one year old girl with a disfiguring tumor on her face. She is small for her age and cannot walk. Her mother is attentive and loving. Whenever her mother steps into the hall she cries softly and says, “Ma.” She is on the ward for a month. Her mother smiles and plays and cuddles and sleeps with her. When her mother is not in the room she lets me hold her and she smells clean and sweet, she is a well loved baby. When her mother is in the room she screams at me in horror, my strange face and my white uniform worn by the monsters in her world. Her mom and I laugh together at her reaction and I leave after a moment. For over a month she waits for a biopsy of the tumor. I talk to the doctors and they express their frustration with the surgeons who keep rescheduling her biopsy. I notice her breathing worsening. The doctor says the tumor is probably beginning to occlude her airway. They begin chemotherapy without waiting for surgery. A few days later I arrive at the ward with a small pink teddy bear for her and find her bed empty. Her mother is sitting in the main ward with other mothers. At first I think she must be in surgery or moved to another part of the ward but she shakes her head and looks down. I take her to the empty ward and hug her, I give her a little money to contribute to the funeral and hand her the pink bear.

A three year old with cancer enters the ward emaciated and edematous. His skin is shiny and taught. His eyelids are so swollen he is unable to open his eyes more than slits. His mother speaks only a few English words. She greets me when I arrive. One day she shows me a picture of him as a healthy boy. She shows me a picture of his younger brother - a healthy baby staring at the camera - and says he died. She says the child’s father is also dead. She does not speak enough English to explain more. The boy looks terrible. He suffers. Then two days after chemotherapy is begun I see him looking beautiful, sitting up eating, all the swelling gone over night, long eyelashes framing big dark eyes.

A five year old boy with cancer had a biopsy and the site where the biopsy was done grew into a huge wound. He is admitted to the ward for daily dressing changes and antibiotics. His uncle stays with him and his father comes to see him daily. His mother has several other small children at home. She comes when she can. He never smiles, he moves slowly and speaks in a whisper. I walk in the room just after the nurses’ aides finish his dressing change. His father is not there. He cries softly and lifts his arms up to them. They giggle and leave the room. I take him in my arms and he snuggles into my neck. After a few minutes his uncle tries to take him from me but he refuses. He falls asleep with his head on my shoulder. I stand with him for a long while then sit on the bench in the hallway receiving comfort and feeling so much love for him.