A big pot hole for my confidence

Many times throughout my days at the hospital I pause, and think to myself "I should really write about this on the annals..." but alas, the transition from brain to post has been a challenge I have not, until this morning, overcome.

Let's see - in short - since August 20th I have caught a bunch of slippery babies, transitioned from watching to being watched and now, to flying solo at the hospital, and (last, but most certainly not least) have gotten married. It has been a blur of a past few months, which have left me curled up in the fetal position in the late evenings sipping on a glass of wine, watching Mad Men if I am lucky, or, as has been happening as of late, baseball with my now husband. Doing anything remotely taxing on my brain has seemed, quite honestly, out of the question.

In general, orientation has gone well. I have done tons and tons of admissions, and have caught less babies than I had hoped, but enough to keep my adrenaline up and my love of midwifery current. I have been feeling rather confident, and ready to take on the challenge of being the sole provider in the room at the always-different moment of birth.

Until yesterday, I suppose, when my confidence took a bit of a nose dive, and reality of being the new provider that I am set in with the steely cold vengeance. The day started out quiet- and from 8:30-9:30 I even broke out my knitting project for a lovely secluded moment in our cozy call room. Then, as most days do, the pace picked up as woman after woman presented to L and D triage with contractions, pain, bleeding, and the like. There was even a woman who came in after having fallen on her belly after being chased by a pit-bull. Somehow, during report, the type of dog was always mentioned, as if it gave the gravity of her case more umph to say pit-bull, as opposed to, let's say, a poodle (she was fine in the end, with a bruised hip only, pit-bull be damned).

Two of the admissions were mine. One, an 18 year old girl from Puerto Rico with a far away look in her eyes throughout labor, turned my confidence around and spun it on it's wobbly head. After admission for spontaneous labor, she progressed without any pitocin or epidural (yes, a rarity where I practice, and something to be stangely proud of, I suppose) to full dilation around 6pm - right before my change of shift. I decided to stay for the birth, my numbers have been rather low and had been with her all day. Her pushing was somewhat disorganized - but, without ever getting the hang of it externally, she managed to move the baby down to almost crowning... which is when the baby began to poo and poo and poo (meconium, thought of as a sign of fetal stress). Pediatrics was called to the delivery as is protocol after meconium, and the nurses changed shift as she was about to crown.

The new nurse in the room was a woman I had never worked with before, and she seemed to be against what was going on from the moment she walked into the room. She was exasperated with the disorganized pushing, with the fact that our sweaty 18 year old was pushing into her face, not into her bottom, and with me trying (usucessfully) to get her up and squatting. The girl resisted, the nurse resisted, and, after two ungraceful attempts, I let her back on her back with her legs supported back, to the position everyone seemed to want but me. Somehow, through my failed squatting attempts, the frustrated nurses coaching, or the tenacity of the pushing mom, the baby crowned. And crowned. And crowned.

It was one of those moments when I wished it was the 1970s and I could just cut an episiotomy and free this child from the tight skin of her mother. But I didn't, knowing the research that perineum's torn naturally heal better than those cut by our scissors - so we waited. And the impatience and frustration in the room seemed to grow as did the beads of sweat on my chest. Just as I looked up to see the fetal heart monitor and get a sense of the heart rate, the head popped through the perineum, restituted, and the baby was born (Mistake #1 - never look up from a crowning baby). I placed her into the birth soup - unslickly- while I clamped and cut the cord... I felt like my hands were adorned with lead gloves rather than latex - and they seemed to move slowly. As I brought the baby over to the warmer to meet the team of pediatric residents waiting to greet this child - I placed the baby backwards on the warmer for their liking (Mistake #2 - head should always face the room). Moments later, there was a low hum of griping that I had clamped the cord too close to the umbilicus for their liking. Mistake #3. So far, without anything bad actually happening, I had annoyed all providers in the room - and was feeling like crawling under the sheet with our 18 yr old patient to hide.

I couldn't do that - but instead delivered her placenta - and she hemorrhaged. She was low risk. First baby. Not a prolonged labor. Got pit after delivery of the baby. And voila. A gush of blood that wouldn't cease. Pit IV. Cytotec in her bottom. Pit IM. Still bleeding. Then I called in the attending and she started to slow down... It wasn't a mistake, but it didn't go well. And I felt like it was bad thing #4.

On inspection she had a 2nd degree tear - like a natural episiotomy - that I sewed up slowly. The nurse that had been so frustrated in the beginning continued to remind me, through snide comments and remarks, that I was horribly inexperienced. I couldn't wait for the moment that, 2 hours after my shift was over, I could leave the room, write my note, and say goodbye. Before I left I hugged and kissed my smiling patient, and told her that I was proud of her. She said thank you. And I thanked the nurse for bearing with me and my newness. She didn't even smile. She just reminded me to take the cart out with me as I left the room. While I know it was the patient who was most important in this case, I couldn't help but focus on the nurse. I walked out of the room feeling ashamed. I was proud of my patient, but was not proud of myself.

Today I feel a bit better about it - it was my first unsupervised delivery ever. In my life. And while it wasn't slick or beautiful - it was safe - and the baby was born. And her bottom will heal. And her iron will replete, and all will be well. I will try to remain proud of myself for what I did right in that room - and not the little things that I did wrong. And so I will move forward to the next birth, and hopefully my list of mistakes will begin to grow less with each birth, and the number of smiles will grow more... both mine, the nurses, and the patient.

Off to clinic. No more time to reflect. I just need to jump back on the horse and continue riding on.

Hospital Hangover

It's amazing how much energy the hospital can suck out of me. Even though I'm still under a strict 'no touch' order until I get properly credentialed in the hospital, I felt like I worked for my money yesterday. And woke up today, feeling the worse for the wear, struggling to open my eyes and leave my cozy bed.

I spent the day battling our terrible computer system and filling out admission paper work in triage. I think I broke the record for the longest time ever taken to fill out an h and p (history and physical) - 5 hours. Perhaps I cheated in the breaking of this record, because the computer froze and my first version was lost entirely... By the end of the day, however, I felt like I had some sort of grasp on the many quirks and minimal perks of this system. The system has the ironic name of 'Sunrise' - which it is anything but. I would more appropriately title it "Darkness."

As the evening progressed into the later hours of night - the hospital got stranger and the cases got more interesting. I saw things that I had only read about in school. (Side note: this attitude always makes me feel conflicted, as it is a direct using of someone else's misfortune. I always want to preface stories like this with the fact that even though I learned from it it would obviously be better if it had never happened in the first place. The women I will write about probably had one of the worst days of their lives yesterday and I am happy only that I could be of minimal comfort). The interesting first case to walk through the triage door was a woman at 39 weeks pregnant who had been assaulted by her husband. I had presented on domestic violence during school and what to do - but in all honesty - a case like this had never confrunted me so directly. As I was leaving last night the husband showed up, started screeming, and created a mini-Maurie Pauvich episode on the floor. It was scary and sad and eye opening.

The second moments of chaos came slightly after. A woman who was 10 days post partum after a c-section came in complaining of "I don't feel well." Then she seized. And seized. And seized. My non-touching order allowed me to take her sobbing friend out of the triage room and explain to her everything that was going on - from afar - then chat her up about her own new baby, and how good of a friend she was for taking her bestie here. After the hanging of mag, and the giving of oxygen and the overhead paging of anesthesia and more chaos on the floor - she seized again. While no longer pregnant, this woman had an obstetrical emmergency that we all fear most.

I biked home late last night, images running through my mind, thinking "Wow. it's not just stuff you read about. Shit like that really can hit the fan." My experience in this job will inevitabley teach me so much about my field. It already has. I wonder what I will learn about tomorrow...

That's more like it...

I almost cried during a birth today - which I haven't done in a long time. It wasn't actually during the birth itself, but during the labor.

The patient was a young woman, in labor with her first baby, and accompanied by her boyfriend and her boyfriends family (mom, and two sisters). Her family was - well, we didn't know - the mom-in-almost-law gave the universal sign for "I have no idea - and don't ask..." with a shrug of her shoulders, a shake of her head, and a gentle roll of her eyes. She had dilated rather quickly, but things had slowed way down while pushing. She had been pushing for almost three hours - which- by any standards, especially my new medical institution, is a rather long time. We didn't think the baby was very big, the position seemed fine, and she was pushing with strength. Her family-in-almost-law was lovely and doting, and things should have been moving more quickly than they were. The docs were knocking on the door - both literally and figuratively - wanting to know what was going on - and starting to use the evil c-word when talking about the plan.

I was at a loss for what to do - we had changed positions, and used all the tricks up my fledgling sleeves. However, the midwife whom I'm shadowing today was almost eerily tuned into the woman's feelings. After a long hard push, the patient started weeping. Not a frantic 'this hurts like hell' feeling - but a deep, mournful cry or sadness. The midwife put her face close to the patients and stroked her hair. "I know this is hard," she said. "You want your own mom to be here with you. His family is wonderful - but you want your own mama now." The laboring woman's tears increased, and we encouraged her to cry as she needed to. She held her boyfriend's head, and cried, and grabbed the hand of her future mother-in-law - and cried. And they cried. And that's when I almost cried.

Voila. In about 30 minutes, she pushed out a screaming baby boy. It wasn't a shoulder or a body part dystocia. It was emotional dystocia. And she let it out. And it worked.

And.... we're back

After a year long-hiatus, I'm back to the bloggesphere. Perhaps inspired by a huge transition and a new job, or requests from disappointed family and friends to start writing again, or perhaps because I missed public reflection on my career choice.

In short... since I posted last - I've graduated from a master's program in nurse-midwifery, passed my boards, applied for and accepted a job as a midwife at a large public teaching hospital in an inner city, visited Costa Rica and Israel, eaten lots of felafel balls and musli, and settled into an apartment with my fiance which feels like home.

Yesterday was my first true-day at work. I am only allowed to observe, as I am not yet privileged at the hospital. What a different place from the small, touchy-feely hospital where I did my training. There are no tubs, and only one doppler for intermittent auscultation (vs. continuous monitoring... the not-evidence-based-standard), which certainly speaks to the lack of it's use and there are no tubs in any of the rooms. There is a contraption, hidden in a closet, called an aqua doula - a portable tub which requires about 10 different small metal pieces to hook it up to be filled in by a sink (!!). Um, yeah, you guessed it. No one uses it.

Perhaps auspiciously, however, the first birth I witnessed there was a precipitous totally unmediated birth by a 19 year old woman. She was in control, in rip-roaring labor, and ready to give birth when she arrived. I learned, in watching her birth, that as new as I am, I have my own style, and was surprised by some of the hand techniques of those around me. I found myself, although rendered to the side of the bed to observe only, desperately wanting to touch and jump in hands first. It was not the birth that I would have conducted exactly, but it didn't matter. I was reminded, that even with 1 clueless but curious male medical student, one nervous ER intern catching, one experienced midwife, one inexperienced observing midwife, one nervous boyfriend, and two nurses at change-of-shift, birth is beautiful.

fits and spurts

This school year is starting out with a squeak and a jolt - in some need of oil to make it run more smoothly. It has been moving in fits and spurts - long 14 hr days to New Haven and back for class, 12 hour call shifts with a beautiful birth, job applications and no success, and lots of down time in between. I have been trying to get ahead on school work - I know that when the wheels are greased this year will fly by - but at the end of some days, it's hard to point to what I really accomplished. Putting together some Ikea furniture, writing a short paper, starting to flush out a lit review for my thesis? Sometimes it doesn't amount to much - and I miss the feeling of being a nurse or midwife when someone says thank you at the end of the day because you worked your butt of for them...

In due time - it will run smoothly. I must seem like a real schmuck for complaining about free time.

Here are a few photos I took on my last day in Lusaka. Things I had been meaning to photograph for a long time.

I jogged by this bike repair/car hub stand often - and always wanted to photograph this guy and his wheels. My last day there I finally was able to meet him. He was piss drunk falling all over himself to allow me to photograph him - happily doing a modeling shoot. Fall from grace?

Perhaps the opening photo for a future power point. The sign from the labor ward outside Chilenje Clinic what I took when going to drop off thank you notes and eye glasses.

A tuck shop in Chilenje.

The drunken friends of the bike repair man, offerin my Shima to eat. I gracefully said no.

Luckily, my PPD test came back negative. But what a scary sign! This was all over the University Teaching Hospital.

Nurse writes in the Times

A nurse after my own heart - writing about her experiences. Trying to gain something new. It shouldn't be unusual to hear from a nurses prospective, but it is. Kudos for the Times.

School has started - but is certainly not in swing.

My new apartment is wonderful here in Cambridge.

Life is trucking again. This article reminds me to take advantage of every moment. Important to remember, especially when things get busy.


http://www.nytimes.com/2008/09/09/health/09case.html?8dpc

Ina Mae in Zambia

A Zambian Midwife and the baby bundle in Chipata.

In my last week here I have been reading Donna’s (my host) copy of Ina Mae Gaskins Spiritual Midwifery from 1977.  This book is groovy in the true Simon and Garfunkle late1960’s sort of way.  Besides being an integral component of the midwifery cannon of literature, it is a fierce, if not dated, reminder of the potential pleasures of having a baby – and the essential role that trust, sensuality, surrender has in birthing [this is an Ina Mae term as is Puss, Rush, groovy, heavy, loving, tantric, psychedelic, telepathic, get high with each rush, smooching….]  

I have really been enjoying it. The first half of the book is birthing stories, each about 2-3 pages, written by women and their partners about their birth experience with the midwives on The Farm – and before the farm existed when they all lived and traveled in a caravan of school buses. (Yes, I’m telling you, those were the groovy days.)  While the stories are full of breech deliveries, premature births, tight cords around necks, and even a stillbirth, the excerpts by the women convey such a sense of satisfaction with their birth experience – even when there are episiotomies and hospital deliveries involved. They talk about loving the midwives, loving their partners, and feeling blessed no matter what the outcome.

The farm midwives placed a lot of importance on working through psychological blocks and interpersonal dynamics between partners on the ability of the woman to both safely and fulfilling deliver the baby.  They tell the women often that ‘tight lips equals a tight bottom’ and encourage the mothers to ‘smooch’ their partners, and get out all of the psychological crap between them.  The men play an integral role in the process – and many women write about how they relied heavily on the energy given to them by the presence of their partner.  They create an environment of love and trust and sensuality – as they say, “a baby should come out in the same way that it was created…”

And then I sit up. And I’m in Zambia. And birthing in the clinics here could not be any more different than the loving, groovy rooms of Ina Mae’s farm (indeed – they are all home births – the rooms designed and created by the mothers themselves).  And I wonder – should this privilege of a fulfilling birth experience come only after basic sets of safety standards have been met? Is this the equivalent of Maslow’s hierarchy of needs? That only after the basics have been met (shelter, food, safety) can one actualize one’s self and experience true fulfillment?  Or is birthing opposite? Is it especially important to create a kind, loving, mother-friendly environment in low resource settings? Or is the question a completely mute point? Is it important for ALL women, regardless of financial status or geographical location or health status to have that kind of experience? 

Yes. To both.

Here is why I think this kind of experience is especially important in a place like Zambia – besides the fact that (I believe) it is a human right to have a humanizing birth experience. 

1) One of the reasons that maternal mortality is thought to be so high here is the low rate of facility births.  Many women deliver at home – with traditional birth attendants – and not in the hospital.  The government has made a big push for facility births because the staff is trained to handle complications and there are more resources than at home.  However, after describing the birthing practices here – including the occasional hitting of women, yelling at them that they are ‘uncooperative’ – and leaving them virtually alone until they grunt and push – my mom said it best: “Why would the women come to the facilities to have their babies?” Even if it is ‘safer’ – it is less pleasant – more isolating- less fulfilling – and therefore less chosen.  If more emphasis was placed on creating a pleasant birthing experience for the women – perhaps that would reduce the maternal mortality just by getting the complicated cases near the interventions that could save lives.

 2) There is physiologic and anecdotal evidence that decreased stress leads to fewer complications in birth.  Separating a woman from her family, her partner, her loved ones, and placing her with a care provider who she perhaps less than trusts increases her adrenaline, which blocks the oxytocin (the contraction, orgasm and breastfeeding hormone), which slows down labor and increases risk of complications. So make her happy and decrease complications.  Sounds easy, no?

But the other parts of me thinks- do all these niceties really matter? Or are they just that? Is it basic skills in safety that are at the crux of decreasing the number of women who die in or after childbirth?  

During my presentation to HSSP to update them on the preliminary results of the project – I talked about the ubiquitous ‘baby bundle’ – as I call it. After the baby is born, it is whisked away and wrapped in a cloth diaper, then a towel, then a crocheted blanket, then a huge fuzzy adult size blanket – so it looks like an overstuffed burrito baby – which is so large in diameter that it is tough for two adult arms to completely wrap around it.  I talked about how that baby bundle reduces any skin-to-skin contact that the mother-baby pair gets, and I included in my list of recommendations that more emphasis be put on the importance of skin-to-skin contact in the hours following birth. 

After the presentation, the deputy director, an American woman, expressed her dismay in this reduced skin-to-skin time due to the baby-bundle, to which her Zambian colleague responded "everyone in this room was born into a baby bundle. We all survived."  Which is true.  It’s a good point.  And it calls into question that, which I think, from my midwifery background, is ‘essential.’

So what is the answer? Should each clinic around the world strive to create the groovy experiences as Ina Mae and her team does? Or should it be a strictly safely first approach? Or is it an obvious combination of the two that is important? 

It is this question of mother-friendly services that brought me into midwifery in the first place, back in 2002 in Tanzaniza, inspired by Mary Kroeger. I think it is this question that will keep me active and passionate about this profession.  I think one thing is clear – there is no harm in providing mother-friendly-fulfilling birth experiences. So why not include it?  We could all use a bit more Ina Mae. 

[There is an international effort to improve the friendliness of birthing practices. It came out of the work done by Mary Kroeger and her wonderful colleagues:  International MotherBaby Childbirth Initiative - www.imbci.org]

 

land of plenty

The past few days I have been feeling really ready to go home. However, after a day of feeling sorry for myself on Monday, I decided to make the most of this last week: to get as much work done as possible, to continue explore Lusaka, and to continue to learn about what it means to be Zambian. 

 Today I decided to my walk back to the HSSP office (my hosting organization) from the hospital instead of hopping on a ubiquitous minibus or jumping in a cab.  I wasn't in a hurry to get back in front of my computer, and have started to relish each moment

 here (a self monologue "why not walk back? when will be the next time you have the luxury of walking down a red-dusty street in africa?").  While I moseyed down Nationalist Avenue, a large wide street past some embassies but without many pedestrians, I found myself walking almost in tandem with a thin Zambian man in a dirty white baseball cap, dirty white pants and a dark green sweater.  He was walking at almost the same pace as me, and after a while like this, I realized that we were alone.  My inner monologue, as ashamed of it as I am, started something like this "I have a computer and digital SLR

 camera in my bag. We're alone on this street... it's broad daylight, and I've never heard of anything like this in Zambia.. but should I switch to the other side of the street?"  It didn't take long before he interrupted my monologue with his voice.  It was obvious that his inner-monologue was very different from my own: "Madame.  I am looking for employment," he said. "Do you have any employment for me?"  

He looked in my eyes. His were sad. His clothes hung on his bony frame and the baseball cap was shading a wasting face.  "I am sorry," I said. "I am leaving on Saturday to go home to America." The minute that came out of my mouth I regretted it: what kind of answer was this? What was I saying? "I am sorry you are desperately poor. I am rich. I am getting on an airplane that cost close to 2000 dollars to buy and heading home to the land of plenty."  I don't think he took it like that - instead he feigned a smile and walked ahead of me.  

I welled up with tears. I have been asked for employment here before - women have shoved their numbers at me, asking if I know of anyone who needs a housekeeper. Men constantly ask me if I want a cab - cars drive by honking as if to say "need a ride?"  I don't know why this man caught me so off guard. I know life here is hard. 

Even I complain that the grocery store is more expensive than at home - gas is almost at $12 a gallon - and even a small beaded key chain runs about $2-3 dollars.  But the statistics say that people here live on $1 a day.  How can that be? It is true however.  The manager of the compound where I live, Vin, makes 200,000 kwacha a month. That's about $75. He supports a family of five.  And there you are, less than a dollar a day per person.  He struggles every day and lives literally hand to mouth.  

(Vin's family in front of my house here)

His wife is pregnant with their fourth child - and has been having unusual pains that prompted him to bring her to a clinic.  The cost of an ultra-sound was about $20 - more than a quarter of his monthly salary- and figuring out what was going wrong was nearly impossible. When he told me his story, I gave him the money - but it is only a small band aid for a huge problem. The next week her tooth was aching so badly she couldn't eat.  Another $20 needed.   Last night, while we were talking, he said "I hate it. I hate only working for millie meal.  Life is worth more than that."  His words rang so true.  The struggle for the poor here is truly heart breaking.

And so my heart I ached for this man who was honestly asking me for employment. And for the cab drivers who sleep in their cabs, and drive me to the hospital at the wee hours in the morning with dust still in their eyes. And for the women who leave their own children alone to care for someone else's for less than $100 a month.   While here the roads are often good, and on the surface this country sometimes looks together, there is true hardship when you just lightly scratch the surface.... I don't know that I've done a darn thing to help this summer.  I don't even know what I could do.  

So I will leave Zambia with love for this country - but with sadness too.  Knowing that as I board my plane to the land of plenty, the people who have touched me will be here. Every day. Hungry. Struggling.  Asking the next white girl who walks down the street if she can give them  job.

Lusaka again

Midwife in Kanyama with her thank you eye glasses

Looking through the window of the train...

Toasting our big night

Adorableness in Zanzibar

Two weeks with no blogging translates into the fact that I was having too much fun...

Where to begin?

Caleb and I took a canoe safari for 4 days on the Zambezi river.... paddling and floating our way down the river with Zimbabwe on our right and Zambia to our left. We camped on 'neutral territory' islands in between - so as to not have to avoid elephants on our camp site (hippos and crocodiles do travel to the islands, so swimming was sadly prohibited...) Our guide, Kambol (he said his parents tried to name him after the soup brand, but that the person who wrote out the birth certificate misspelled it and the name stuck) was fantastic. He was a one man show, as neither Caleb nor I are particularly expert at canoeing and camping 4 course dinners over a fire) and knew so much about the land and the foliage and the animals that surrounded us.

To the midwives among you - we learned about a type of antelope that can retain their fetus and stop themselves from giving birth for months and months during a drought - and that when born, the baby is not any worse for the extra months inside.... He told me the name, but I've forgotten now.

After we returned from the trip, we spent a few days in Lusaka, and I handed out my thank you gifts to the midwives that participated in my study - safety eye glasses to prevent against transmission of HIV if there are any 'splashes' of bodily fluids. I spent a fun and santa-clause-esque day driving around to all of the compounds in which I worked, dropping off three pairs per clinic. The midwives were very appreciative, and it felt like great closure. I will try to post a picture if the internet cooperates.

Then we left on a trip into Tanzania with some friends. As a train lover, and an over-night-train-lover especially, I had planned for us all to take the train from an industrial town about 4 hrs north of Lusaka (Kapiri Mposhi) to Dar es Saalam. It was supposed to be 44 hours (2 nights)- but ended up being 52 - and the ride became VERY long and greuling. It perhaps was my fault, as somehow I thought that Africa would magically transform into India, and we would be served hot chai by the chai-wallas in the morning and indian food for lunch. Instead, it was chips (french fries) and pink sausage on the menue. Yuck. Ok, sometimes chips are delicious.... but enough was enough after 3 days of fries.

Dar captured my heart in a surprising way in an India-meets-Africa sort of experience. We did get chai there from a local shop, and Caleb managed to put down a whole plate of curry and chapati before 9am, which impressed me. I was content eating a half of a papaya drizzled with lime juice with a spoon - trying to recover from french-fry-overload. The markets were full of colors and energy and men on bikes and mosques and cows and - well - it made my heart soar. If I can say this only once without getting in trouble - it made me wish I had picked a different city to base this study. Ok. That's out. Moving on...

Zanzibar was just pure love. And our lodging for a few days was called "Paradise beach bungalows" - a name that could not have been more fitting. I could go on an on about the turquoise water, the Swahili culture and food, and the joy of relaxing, but I'll spare you.

I'm back in Lusaka now. I have a week to tie things up here: present preliminary results of my project to my hosting organization, finish handing out eye glasses, buy last minute gifts, and say my goodbyes.

People keep asking if I'm ready to go home - and I think I am. I am sad to leave Africa. But at this point I feel like if I was to stay longer without another project or mandate I would be spinning wheels.

And, to continue with the food theme, I can't WAIT for a huge salad.

"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.

A week under my belt

Each day this past week I visited a clinic here in Lusaka and hung out with the midwives in the Labor Wards. It has been the best week so far - and it feels all warm and tingly to be doing that which I set out to do.

My initial sense? The midwives here are overworked and under paid. They are passionate like midwives around the world about what they do. They are skillful and are hungry for more techniques to save lives and reduce morbidity. They LOVE oxytocin and active management. The only reason they are not using it is if there is not oxytocin available. In some of my interviews, which I expected to be a careful unpacking of attitudes and barriers, I have been getting answers like "I love it" and "It works." The interviews that I expected to last an hour are barely 15 minutes. One midwife actually said "Why do you keep asking me about the same thing?" Hmmm...

But not all is well in the clinics. Mothers are separated from their babies almost immediately and are asked to get up, clean themselves off, and wash their own linens about 10 minutes after delivery. The babies stay stacked on an empty bed, wrapped in a HUGE bundle of blankets and towels, waiting for their mother to nap and rest before they come together. There is very little attention paid to the post partum period. Women are discharged 6 hours after delivery. When I explained that in the US they stay for 2 days post partum there were gasps. "What do you do with them for two days??" Ah, America.

I will spend a few more days observing in Lusaka this week - and then will take off for a series of trips to observe further out. Thursday I'm leaving for the Eastern Province, bordering Malawi... then will return Tuesday to head South to Choma and Mumbwa... then North to Ndola. I have expanded my sites because a) why not? and b) a few days in one place seems like enough time to become acquainted with the culture and the practices of a place.

So, 25 births later, I'm feeling like a researcher in Lusaka at last. Time is moving fast now and I just hope I can finish that which I set out to do.

More soon.

Back on track

Only a week later than promised - we have IRB approval, sanction from the Ministry of Health, and have officially begun data collection. Today I traveled to a health center in the middle of one of the largest compounds in Lusaka. THAT was the 'Africa' I was expecting, strangely. Kids with swollen bellies and no pants running around little concrete shacks. Smiling women behinds stalls of fruits and veggies - right next to the chickens and the goats. Women with precariously balanced watermelon slices on a platter on their heads - that somehow never falls amidst the bumpy roads.

I saw only two deliveries. Five delivered before our arrival (a research assistant and myself) and two were in active labor when our ride came. Tomorrow I will return and hopefully see many more. This week in Lusaka - and next week I'm (finally) on the road.

Initial impressions: 1. Although (or because) there were many less resources (no surgery, no pain meds, not even oxygen for the mom in case), the clinic is a much kinder environment in which to give birth than the big hospital. The windows were open. The midwives were kind and skilled. And women labored naturally, vocally, physically - without any yelling at all. Birth there felt as normal as grocery shopping. Something you do. Sometimes it's a pain. You get something yummy when you're done.

After delivering, one woman got up and WASHED her own chitenge in the sink (big piece of printed fabric... kanga, panya... etc) within 15 minutes.

God damn. Women are amazing.

Kindness

I had written a whole entry in my head after a long day of observing at the Hospital on Tuesday - but when I got to the office today - my Macintosh died. Now computerless, and feeling disoriented, I write at the end of the day from an internet cafe.

Tuesday I piloted my new and beautiful data-collection tools. I observed a hand full of births - and interviewed the midwives briefly. The births were mind-boggling in their routine-ness. The women delivering at the hospital were not treated at all as if this was a special day. On the contrary, they were treated as if they were doing something rather gross and animalistic. The woman deliver on flat beds (all on their backs - they are lucky to have a metal bar on which they can rest their head while they push. There are no sheets. women bring their own fabric - and if there is none, well, it's black-garbage-bag plastic to lay on.

But the surprise - or the noticeable component - was not the lack of resources. I expected that. It was the unkindness with which some of the midwives treated their patients. One, when seeing his patient grunting to push, scolded her and made her cross her legs until he had time to catch the baby. When he did come back, about 10 minutes later, he started waving his scissors about - near her perineum saying "If you do not push this baby out in 10 minutes I will CUT you (snip snip with the scissors) - or you baby will die...."

Luckily, she did. While she was pushing, however, he didn't like the effectiveness of each push and grabbed her lips and held them tight - in a mix of Nyanja (the local dialect here) and English- he said something all to easy to understand "Enough with the drama, drama, drama! Push with your mouth closed."

I used my new learned midwifery skill of biting my tongue and sitting on my hands or I think I would have jumped on him. She was also HIV positive - and on PMTCT. And I really hoped that he was not treating her badly because of that. Who knows. Stigma runs deeply.

They were not all so dramatic. However, it made me wish that my first idea for a project - looking at what happened to a mother-friendly-organization - had worked out. At the end of the day, I didn't care if they used active management - I just cared that they treated these women like the goddesses - or even the humans - that they are.

On another note- the 'expidited' IRB process still hasn't given birth to a letter of approval. Thus, full data collection is still on hold. We are INCHING closer by the day.

So, another day, another story. I'll keep you posted. On the flip side - Zambia is growing on me. It is the perfect weather to run - and the roads are long and dusty.

in conclusion?`

Many things have happened since my tearful post last week - and besides my sore throat today, I'm feeling much better.  

1. The organization paid the fee. I had nothing to do with the decision. They will meet today - so my fingers are crossed that it's a yes, and I will have to spend more time ruminating on the meaning of the on the un-ethical behavior of the Ethics committee.  

2.  I spent a night dancing to Congolese Rhumba at one of the few dance clubs here in Lusaka. One of the people who came dancing with us is a new friend Nathan - who happens to be  a Zambian wedding choreographer. He tried his best to teach me his moves (picture a slowed down and more controlled version of west-Africa dance).  It was a great evening - better still because of the un-sexuality of the dance floor. It was mostly young men - showing of their moves for each other - completely un-self-conscious and ready to bust a move at every song. Quite a refreshing change from the bop-your-head-to-the-beat style of may American men. 

3.  We conducted a training for our two fantastic research assistants. They are both experienced Zambian midwives who had great advice on the phrasing of questions.  We met outside, and ate insheema (a local maize mush) with a delicious vegetable called "rape" (not kidding) - which is like, if not exactly, Swiss Chard.  Once this project gets rolling, they will be a joy to work with.

4. I got a letter of permission from the Ministry of Health to pilot the data collection tools.  Yeah. One accomplishment. This morning I took the tool to the director of the hospital, who was at another meeting and will not be around until tomorrow. Argh. Stymied again.  "Don't worry," my friend Masuka said.  "You'll get used to the Zambian slowness. You people always do."

Hopefully tomorrow.....  

It's rare that I feel angry. But today I feel furious.

We have been promised almost daily since my arrival that "tomorrow" we will have word from the ethics committee here to get approval for this study to proceed.  I've gotten a lot of "don't call us, we'll call you" - when I keep bothering the poor secretary.  So today I called again, a bit more desperate, and asked to speak to the head of the committee. She explained that we wouldn't be reviewed until the end of the month? 

WHAT?? 

JUNE 30? 

That will add up to a month of waiting.

She has to be kidding.

There was one caveat. We could pay 2.5 million Kwatcha (about $800) to organize an expedited meeting that could be called in a day.  

Here, I have found out, officials are paid a "sitting fee" for each meeting that they attend. People in lots of health organizations  are impossible to get in touch with because they are always in meetings. And now I see why - what a supplemental income strategy.

So my project has been sucked into this fiasco.  It is possibly a combination of a miss-communication (the secretary hoping it would be passed, so she led me on in a way), the huge wall of bureaucracy with a hint of corruption peering through the silver walls...

I am trying to spin this in my head as a cross cultural experience (yes, thanks mom).  Perhaps it is a different sense of time,  a lack of a sense of urgency. I joke with people here that there is "Zambian time" and "America Time" when we call a meeting. A 9am meeting in Zambian time means between 10 and 10:30. In general, people here have been nothing but generous.  However, in this situation, I feel like I want to pull out my hair.

In the end it leaves me feeling like I want to cry.  I am here. Now. I would love to get this thing off the ground.  We are trying to circumvent this by talking to people with power. At this point, my fingers can only be crossed  - that, or I (or the organization I'm working with) can cough up $800. Or, I could think of a fun plan to do for the next few weeks and take off for greener pastures.

Oy.

Cloudy day

Two unusual things happened yesterday.

1. It was cloudy here. 

Strange to say - but every other day has been cloudless and getting into the 70's. Yesterday it was windy, cloudy, and cool. It feels like fall here.  The clouds weren't ominous - or threatening of rain - just grey - and pervasive - and preventing sun.  Today is the same. I hope we see sun again soon.  

2. I finished two novels in the span of a week. 

I don't remember the last time I've done that.  After six here it's pitch black out - and there isn't much of a night life - so I've been staying in most evenings. I guess that's how one finishes two novels in a week.  I'm only on week 2 - and I am already half done with the books I brought. Hmmm... 

I'm anxious to get this project started. It's been a week and a half of prep work - paper work - office time. We still don't have local ethics committee approval - which means I can't even go into the hospital to pilot tools.  I've been talking to lots of people working in this field - and I am starting to get the impression that Active management - what I'm looking at - is being done pretty routinely in Lusaka.  Yesterday I went to a grand rounds at the hospital here - on the topic of a garment they are piloting to reduce death from hemorrhage - in their presentation they mentioned that they've seen lots of preventative measures being taken (ie: active management) and sort of brushed it off.  I have this fear that I won't find much of anything interesting at all.  I guess, stepping back, that 100% compliance is interesting - it means that the trainings worked. That there is a shift in culture.  

Oh well, hopefully with more prodding and nudging and bugging this IRB thing will go through and I will be able to get started. Data collection is scheduled to begin on Monday. We'll just see about that...

Population

Zambia is not a very densely populated country. Indeed, the whole population (roughly 11 million) is smaller that that of the city of Lahore in Pakistan (almost 15 million). There is not the hustle-bustle here of urban or rural life. In the rural areas, although I have not yet visited them, the towns are said to be miles away from each other, and each one sparsely populated with only 20-100 people living within the town walls.

Not only does this make for a non-hectic (almost suburban) experience when walking around the streets of Lusaka (indeed: after a week here I can count the number of times someone has asked me for money on one hand: 2), but it poses interesting challenges when developing health care interventions for the rural areas.  

On Friday I sat in on a professional meeting for people working on pediatric health in Zambia. New research was presented and discussions were had regarding how to decrease the extremely high neonatal mortality rate.  One pediatrician shared her research regarding the intervention of barefoot neonatologists - that is, lay people trained in basic neonatal health and newborn resuscitation to accompany traditional birth attendants or to visit new moms shortly after birth.  This intervention has been rolled out in India, and in some areas, has reduced neonatal mortality by 30-40%.  However, an interesting concern was brought up: with such a small population, and such sparsely populated rural areas, would a trained lay-person have too little to do to maintain upkeep of their skills? If they only had three or four babies per year in a small town of 20 - would that be enough?  Until you are REALLY comfortable - clinical skills certainly fall under the category of 'use it or lose it' - and they are afraid it is a 'lose it' scenario.  But, with such a small population - it is not worth putting one of the rare doctors in these towns. So that is the challenge of Zambia (ok, one of the many). One solution is to have a system set up where doctors literally fly into rural towns when there is an emergency - but this, too, poses challenges.

The sparse population has affected me as well. The entire time I've been here - I have kept waiting to feel like I am in "Africa." This has begged lots of reflection on my part around the questions of my biases, my expectations, my sterotypes of "Africa." What was I looking for? What was I expecting? Why, when Zambia is almost smack-dab in the middle of this continent, can it not feel like Africa? And I think it comes down to that feeling of being overwhelmed that I am used to - or that I experienced in Mali and Kenya long ago.  I am not really overwhelmed at all. Perhaps this is due to my cush-living situation in ex-pat ville, and perhaps it is due to Zambian culture. It is not a pushy culture. People so far that I have meet have been nothing but lovely, and rarely pushy at all. Even at the markets. Perhaps it is because English is used widely here - so I have been able to communicate rather freely. Perhaps it is in part simply due to my incorrect expectations and assumptions about what this country would feel like on the outside.

Saturday,  in a quest for hustle-bustle, my new friend and I ventured into the down-town area on Cairo-road. I had been warned to 'not get excited' - that it is little more than a row of Banks.

It was more than banks, and my friend and I found a big (ish) Zambian market with local food (ensheema - sp?) which is corn paste - similar to ugali - and fried fish, chicken, and dark greens.  We found pirated DVDs, lots of car parts, sink parts, and the nuts and bolts (literally) of life. Hair salons teeming with women getting new-do's, extensions, un-extensions, braids... and some tailors with black singer sewing machines and foot-pedals.  

I brought my camera - but was too nervous to take lots of photos for some reason.  A few people said 'NO' with their hands when I lifted it out of my bag, and one woman asked for money.

The photos aren't great - and I tried over and over to upload them - but the connection must not like it.... I'll try again later. 

Today I'm going to visit a midwifery class to get a 'feel' for education here.  It will be my second observation, the first of which led to many insights indeed.