"My Dear - this is Africa!"

It's amazing how much can happen in a week. I feel like I'm standing in a very different pair of shoes than I was during my last post - although in reality it's the same warn pair of Dansko clogs.

1) Caleb arrived on Thursday night. It is wonderful to have him share this place with me. We had a lovely and relaxing weekend jumping on and off mini buses, going to the market-in-the mall, and reading at home.

2) I returned from Ndola - on a bus - after waiting 4 hrs for the bus to fill to capacity and FINALLY leave the station. No sooner was I done thanking god for the departure than on came the terrible Nigerian soap operas played at unimaginable decibels. After covering my ears and whimpering for a while - the man behind me laughed. "My dear - this is Africa!"

Ndola was a beautiful little city - with wide tree-lined streets, a 'Shop Right' super market, and a nice woman selling hard-boiled eggs and delicious oranges on the corner between my guest house and the hospital. I spent a full three days there - and in total - only observed 7 births. I decided, as most babies are born in the wee hours of the morning - to switch my day shifts into evening/night shifts. My plan all but failed there - as in 11 hours - I only saw one normal delivery. Although my eyes were tired, my confidential envelope was all but empty. Ndola hospital was very well equipped however, and did not buck the trend that I have been seeing: Active Management is used and loved by the midwives.

The last morning of my trip, acknowledging my bad luck at the hospital, I hopped a cab to see the busiest clinic in one of the surrounding compounds. What luck! I saw two beautiful deliveries in one morning. Both done by students- with the midwife looking over her shoulder.

So - my total number of birth observations is at 58 (6 higher than expected). I am now heading into the next phase of my project - the analysis and the closure of sites. I have spent the day coding - and making thank you cards. As a gift I am giving protective eye glasses - as all the midwives wanted mine. In my interviews, when asked about what was needed, many said "protective clothing." While 30 pairs of goggles won't save anyone necessarily, hopefully it can prevent one splash from getting in a midwifes eyes.

Wednesday I leave on a canoe trip for a few days. Time to see some hephalumps and woozels.

Warning – this is sad. Don’t read if you’re already not having a good day.

[note: this is posted from Ndola - since I didn't get to an internet cafe in Lusaka. More on Ndola soon...]


I am back in Lusaka for a day before heading off again – this time to Ndola, the site I proposed in the very beginning. Ndola does not have a rural catchement area. Instead, it is smack in the middle of the Copperbelt province, one of the richest, I hear, due to the copper industry that funds most of Zambia. With the advent of wi-fi and silicone cables - and the reduction of copper cables being used – this province in Zambia has apparently been through some major economic shifts and down turns in the past decade or so – and is now just starting to rebuild. There is an anthropological look at the social ramifications of this down turn by James Furgeson called Expectations of Modernity. As a non-academic-anthropologist, it is a bit hard to get through, but the parts I’ve read have certainly been interesting – and I’m curious to see the capital city tomorrow.

My last 2 days in Choma had a strange air to them – there was more death than there should have been, that is for sure. There was a maternal death on Thursday night. Her baby died as well – both from a ruptured uterus diagnosed too late. I met the woman during my evening – when I had said I was returning to the hospital. When we arrived, she was 8cm and screaming. Then she got really really quite. Unsettlingly so – and curled up into a ball except when she sat up to vomit. With the weak stomach that I am known for, I often left the room when she was vomiting – having a bad feeling about the whole situation. This was not the typical transition vomiting that women are want to do before finally pushing out their baby. The midwives were aware that her condition had changed. In my field notes that I try to keep during each day of observation – I wrote “The midwife just came in to call the doctor – she said ‘her skin is cold and clammy.’” Her BP was stable, but something was obviously wrong. I did not know HOW wrong it is – but will NEVER again miss the obvious signs of a uterine rupture. I never put my hands on her. I never felt her fundus. I asked for her consent when we arrived so that I could observe her delivery – which she sweetly gave and signed the paper herself. I don’t know what to do with that paper now. Realizing that she was more sick than about to have a baby – the RA and I left, as it was late. When we arrived the next morning – and asked how she was – we were told she had died on the OR table (in theatre) – at about 12:30. She had ruptured. The baby was dead and high in her abdomen. She was in shock. I almost threw up.

That day, a premature baby was born. I think it was about 28-30 weeks gestation, but the young mom did not know her LMP(last menstral period) and came in at 7-8cm dilated. Anyway, there are no tocolytics, so if she’s in labor, she is going to deliver here. The baby was born – Apgars about 4 and 6 – meaning the baby was limp, but breathing. It was weighed immediately (yes, that usually happens here before the placenta is out or the oxytocin is given) and was 1.3 kg – which is 2.9lbs. After an hour, an oxygen tank and adult size nasal canula was brought in, and put on the now blue baby – that the midwife had tried to resuscitate with the resources available. The oxygen was taped on to the tiny face as best as it could – and I watched the baby throughout the day – continue breathing. Knowing the value of kangaroo care for premature infants – in both low and high resource settings (where the baby is kept next to the mother for warmth – instead of on the artificial warmer wrapped in blankets, as all neonates are here – I asked if the baby was ready to go with it’s mom for Kangaroo care. The midwife told me that no, this baby (whose oxygen had just been removed) needed to stay on the warmer for ‘observation.’ The only trouble was that it was all alone, and rarely observed, because the midwives were busy doing something else [side note- usually 2 or 3 midwives and no nurses are responsible for all admissions, discharges, complicated antenatal cases, post partum mothers, laboring mothers, and referrals including pre eclampsia, eclampsia patients, and any one else who is pregnant and walks through the door]. I tried to keep watch as best I could, but left around 5.

In the morning, I returned, and saw the mom. “How is your baby?” I asked her as she was walking to the bathroom to bathe. “My baby is dead.” She said. Her eyes welled up with tears and she turned away. Again. I went to an empty bathroom and cried. I do not know if I could be a midwife here. There were other stories, but I won’t go on.

So – 6 deliveries were observed in total during the 3 days in Choma – but I have to say, I was ready to leave when I was picked up on Saturday afternoon. I feel guilty walking away – without having done anything really to help. I put on a pair of gloves sometimes to help a midwife hold something, or pass her something – or adjust the oxygen on a baby – but I have not really helped. I don’t even know what I would do. Make recommendations? As if that’s enough.

I hope Ndola will not bring with it the witness of so much sadness. But this project trecks slowly on – and I have almost reached my target for numbers in both interviews and in observations. I am ready to see some elephants, giraffes, and stare at the wide open and star filled sky for a bit.

Kafue river with no fish

Outside Chipata General Hospital with the sun setting

Labor ward of Chipata General Hospital

Partograph and nurses hats in Chipata

The lovely Midwives at Kapata Clinic

I am sitting in one of the tackiest rooms I’ve ever stayed in. Brick-a-brack doesn’t begin to cover it. The under curtain is lace – the outer curtain is a fake patchwork of animal prints and bad drawings of the big 5 safari animals. The floor is tiled in a pink and gray tile that could be confused for dirty if you don’t look carefully and realize the gray splotches are part of the design. The over-stuffed love seat in the middle of the room is mauve and velvet and hard when you sit on it. There is a TV, a lamp and a dresser pushed up against one wall and a fridge pushed up against the other with bad painting of a lion hung 2 inches from the ceiling molding.

But – I love that I’m on the road. I’m sharing the room with one of the research assistants working on a complimentary project. She’s wonderful – an experienced midwife and trainer, who has been hired to help out with data collection. It is 7:30pm – and we are taking a break before we head back to the hospital to see if there are any deliveries. Apparently, July 10 is not a popular day to go into labor in Choma, Zambia.

I did watch one delivery today- the 18 year old girl – in my opinion – did wonderfully. But the midwives didn’t happen to agree. I watched, clutching my binder with data collection tools, as they yelled at her, and hit her legs and once her face when she was screaming, as she pushed. “she’s an un-cooperative gul.” One midwife said to me. I had to bite my tongue. Active management was used in that delivery – but I can’t say that I cared much. In just standing there and observing, I felt complicit in her meanness. I suppose these are the ethical dilemmas that the Downs committee encouraged me to think about – but meanness wasn’t on my mind then and I’m not sure I handled it well. I tried to compensate by telling her over and over what a good job she’d done – but I don’t speak Tonga – and I’m not sure she understood.

While that is the delivery experience fresh in my mind - I don’t want to paint that picture at all of the practices here. I have watched and interviewed some wonderful, skilled and kind midwives that put the lives of their patients (clients – as they call them here) ahead of everything else. They love active management, not because it cuts down on their work, but because they have said over and over that it truly cuts down on the rates of hemorrhage. They are upset when oxytocin is out of stock, and they reserve it for the clients at increased risk of hemorrhage when they are low. This has been the theme in all the clinics I’ve spent time in Lusaka, and in the clinic and hospital I visited in Lusaka.

Along wit the good – of course, I’ve seen the bad. After the discovery of a lack of fetal heart in a woman with polyhydramnios (too much amniotic fluid)– the doctor said “this is like the Kafue river – but with no fish.” People laughed. I did not. I also saw a footling breach (baby is born 1 foot first) that was ignored for a while. Unbeknownst to me, the mom was just laying on the bed with a half delivered baby….

There is very little labor management. Women are lucky to have the fetal heart checked every 4 hrs – as they are supposed to. There is NO Doppler, no sound of fetal heart in the room, and very little attention paid to the fetus. I have seen a few patients go to c-section (Cesar – as they call it hear) for fetal distress – but I’m not sure how they discover that.

As for the rest of Zambia – it continues to grow on me. It is a no-frills place in the most honest sense of the word (except the frilly curtains in my room). Life here is just life. Unadorned by crazy fashion, fancy food, and lots of hobbies. People are surrounded by death – and life – more than I am used to at home. There is always a funeral or a funeral procession – or talk of someone dying – and living – and life.

I have 1 more week of traveling and data collection – then the project slows down a bit when Caleb arrives. I feel that – while I have not analyzed the numbers – I have a good sense of what is happening in the urban and peri-urban clinics here.

I may just have found the answer to my question though...

from the road

Since I've last written - I've FIANLLY ventured out of Lusaka. I drove to Chipata - on the boarder of Malawi - with some friends here to do some work and play a bit as well. It was so refreshing to leave the capital city - and I feel like I've finally seen some of Zambia.

I'm on the road again - this time in Choma - which is half way to Livingstone. I've decided to change the structure of my research a bit - spending only a few days at each clinic or hospital. Each place has a culture of it's own - so many days seems redundant. Thus - I've seen 7 or 8 clinics - in stead of 2 - and feel like I'm painting a more cohesive picture of what's going on.

I have many thoughts - which I will write up on my laptop and post tomorrow.

Cheers from Choma.