Labor of Love Booklet

   Labor of Love Booklet by  

Baby Maria

Baby Maria is sitting on the bed next to Trish Perkins.

Baby Maria wasn’t an orphan when she came to Maforga --not exactly. Her father is still living, but he’s old. Very old.

A month ago, he brought her swollen body to Roy and Trish and begged them to help. Her mother had just died of AIDS in the village and she was not far behind.

Afflicted with a severe case of kwashiorikor --a form of malnutrition due to protein deficency—she barely moved from the pain in her joints and the swelling in her limbs. It didn’t help any that she was also HIV positive.

When I first met her, she was sitting up and considerably improved. But even though the swelling from the kwashiorikor had subsided, she still struggled to gain weight.

But we were hopeful.

It was hard to tell her age by looking at her though. Had I gone by the look in her eyes, I would have guessed her to be well passed a hundred. But in actuality, she was about 10 months old. The thing was... she weighed little more than a newborn.

Only time would tell if she would improve.

We prayed for her daily while her caregivers pestered her hourly to eat even the smallest of morsels.

I checked on her from time to time. But when I did, I usually found her sleeping. Her eyes closed, her chin tucked, and her twig-like frame lay listlessly on the cot. When I stroked her face, she wouldn’t flinch. When I pressed her hand, she would not make the slightest acknowledgement.

Once she opened her glassy black eyes to look upon her aggressor, but quickly unimpressed she closed them again to rest. What little energy remained was focused on keeping her heart beating... and her lungs full of air.

Day after day, her caregivers spent hours getting her to swallow a few bites of fortified porrige, but even the will to swallow had passed.

She had clearly given up.

Life clung only to the frayed edges of her soul and stirred softly in the ever darkening expression in her eyes. It was clear she was trying to say goodbye.

Everyday she fought a little less. Everyday she drifted a little further away.

Yesterday she died.

Finaly.

Is it wrong of me to feel relieved? Do you think me heartless for it? I’m heartbroken she passed away, but I’m thankful her suffering has ended.

She is the very reason I want to work here –she and her nameless mother.

Why do we have orphans dying of AIDS in Africa? There is no trite and simple answer to that question. There just isn’t.

But roll back the calendar a year and a half to when Maria’s mother first conceived. How much different could her pregnancy and birth have been had she had a midwife to help her in the village? How much healthier could she have been had she taken the retrovirals... or had access to them in the first place?

What if during her birth, her midwife could have reduced the risk of transmission of HIV and Maria had been born free of this corrosive blood sucking virus?

What if... what if...

I’m not saying I have the solution to all the woes of Mozambique. And I’m certainly not saying that I can save them all.

But seriously what is the alternative... to do nothing? –to watch them die slow, emaciated deaths? --to plant their brittle bones in the ground and walk on?

Is that really an alternative?

Please pray with me today. I seriously need your prayers. Right now all the doors seems to be curiously closed to me and what I want to do. Please plead for God to open the doors and grant favor for me to discuss my ideas with the local powers that be.

I need to start somewhere. Why not here?

"Missing" --Video on Maternal Mortality

“Missing” A message about maternal mortality from Big Yellow Taxi on Vimeo.

Deep Transverse Arrest

 

Nunu’s first birth ended in a cesarean. She was in labor for several days by the time she got to Wau. The doctors explained the baby was transverse and performed a cesarean. The baby lived just two hours.

The evidence of her loss came in the form of a copper streak an inch wide which sprouted from her pelvis and pushed raggedly past her belly button --a classical cesarean scar. Tiny dots ran along each side like a fence post; it must of hurt to get those sutures removed. 

She had been coming to our clinic for several months before I met her. Up until then, Margaret or Sarah had done her checks.

I clearly remember meeting her that day for two reasons. One, she discussed her case in English. And two, she really didn’t like what I had to say.

At that time, her baby was breech. I told her it wouldn’t be safe for her to deliver anywhere but a big hospital. There were just too many risk factors.

She argued with me, saying that she wanted to talk to Margaret. When I called her in for a consult, Nunu broke down in tears and wept on her shoulder. She categorically refused to consider going to Wau.

Then together we explained the risks. She needed to prepare for surgery and consider going to Wau even to labor. She shook her head in refusal, flashed tear-filled eyes my way, then took her book and hurried off.

Fast forward another month or so, to earlier this week.

She arrived mud splattered and soaked to the bone in the middle of a storm. She was in active labor.

One look at her file and I was concerned. Why had she not listened?

I told her that since there was no way we could get her to Wau that night, we’d let her have a ‘trial of labor’, but ultimately if there was no progress she’d still have to go. 

She listened... but didn’t at the same time. Her jaw was set in refusal.

Since she was already 8 cm dilated with an intact membrane, I let her labor on her own. Progress was slow, but I remained hopeful.

But then again, I didn’t have many options. We couldn’t drive her in the middle of the night. The storm only made things worse. Plus... she wouldn’t even consider it.

Margaret took over her care that night. She explained that although she was well past fully, Nunu was not pushing right. Perhaps she didn’t know how or couldn’t.

I assessed her again and found the head to be at a zero station and slightly swollen. Her pelvic outlet seemed more than adequate. But he did palpate to be big.

Margaret continued to explain to them the need for a cesarean while letting her try and push a bit longer. Fetal heart tones were fine, and Nunu was determined.

But after a few more hours of no progress, Margaret told them she’d need to leave first thing in the morning for Wau. She went to get some sleep and left them to discuss it amongst themselves.

The translator working that night said Nunu’s mother was upset we were ‘giving up’ by going to sleep and took her home. Nunu and her family left in a hurry around 2:30 am.

When I woke for my shift, I expected to be greeted by a baby or a transport. But the clinic was empty. I couldn’t understand why they left.

There was little I could do but pray. So I prayed and prayed. In fact, I could do little else.

Had she gone home and delivered? Did they take her to another clinic? What happened?

I worked through my worry by doing prenatal after prenatal. I finished just after lunch then went to a staff meeting. By 4 pm, I was called away early because she’d returned.

Fourteen hours had passed since she’d been checked. Fourteen long hours...

I asked her what they’d been doing all this time but they were silent. I pressed them only to learn they’d simply gone home. They didn’t call a TBA. They didn’t go elsewhere in town. They simply went home and did nothing.

Digging deeper, I also learned her contractions stopped shortly before dawn.

However when I lifted her dress to check her baby, my heart jumped in my mouth. I couldn’t believe my own eyes. Bandl’s Ring had developed.

Bandl's Ring.

(For those who don’t know, Bandl’s Ring is when the upper uterine segment separates from the lower uterine segment, forming a band around the belly. It is a sign of severe neglect of an obstructed labor and proceeds uterine rupture.)

I asked if I could take a picture and told her that she needed to go to Wau immediately. She agreed to both. They realized she was dying and had gathered the money. They’d come back to ask to use our ambulance.

Thankful for this change in heart, I set the wheels in motion. The drivers had to be called, the ambulance needed to be fueled, and I needed to write her doctors a referral.

Although her blood pressure was stable, Nunu was deteriorating fast. Her baby was alive but  had developed a sinusoidal heart rate pattern. This is a serious indication of imminent death, and I told her so.

(For those who don’t know, a sinusoidal heart rate pattern goes high and then low and then high and then low again. There is never a stable baseline but it typically stays within a normal range and is a sign of severe fetal compromise.)

-- “Nunu, if you don’t get this surgery soon both you and your baby can die.”
-- “I understand.”
-- “I’m not saying this to scare you. I just need to know... Do you know Jesus?”
-- “Yes. I am a believer,” she said then turned away.

Fortunately, it didn’t take us long to get her on the road. But I had my doubts.

She’d be arriving at the end of the day. Most doctors aren’t working late night shifts I’m told. Plus, the last woman we referred for a cesarean was told to wait another 8 hours after arriving because her baby had died. That girl eventually got surgery, but died minutes later. Would Nunu have a similar experience?

Dark thoughts nipped at my heels. Yappity dogs. Fierce hounds. My only retreat was prayer.

Lord, may Nunu live. May her child somehow survive. You knit this precious one in her womb, now please bring him out. I’m begging for a miracle.

I woke the next morning to learn she’d not had the cesarean. At first I was nauseated, but again I prayed. There must have been a good reason.

Later that day, I learned that by the time she’d arrived the baby was dead and she was semi-conscious. She was too unstable for anesthesia and was pale. The doctors didn’t want to perform a surgery just to have her die on their table.

Plus, they wanted her family to donate blood. She couldn’t have the surgery until they had 2 or 3 units of blood standing by.

When I learned of this new rule I didn’t respond well. They were doing nothing! Why were they doing nothing? But again God reminded me that they must have good reasons and I prayed.

Lord, I’m tired of sending people to Wau for help and they never get it. I’m tired of hearing they have no blood there and that’s why this girl or that girl must die. Please, Papa, do a miracle!

I later learned that she has my blood type and volunteered to donate. But my going there was not an option. Instead we helped organize her family members in the area and got them there.

But it was all for naught. She died later that night, never having woken from her coma.

I understand why the doctors in Wau didn’t take her into surgery. I understand their need for blood. I even understand their anger with us. They thought we were wrong to keep her so long or allow the trial of labor.



What I don’t understand are Nunu’s choices. Why did she argue when we told her to deliver in Wau? Why did she come after a day of active labor in a rain storm? Why did she abscond in the night when we wanted to refer? Why did her family let her get so bad before taking action? Why didn’t she plan ahead and set aside the money? Why didn’t she listen?

I don’t ask these question in judgment. I ask them in genuine confusion. Why?

Perhaps with time, I’ll better understand the social and economic limitations of the women here. Perhaps with experience, I’ll be able to better help them maneuver any obstacles. Perhaps with time, fewer women will die. Perhaps.

Perhaps not.

Nunu’s death burdens me. Please pray for her family. She was well loved and known in this community. Her funeral is tomorrow.

Two Liters Too Few.

Her precious children.

Angueth came in barely conscious. But by the time I was called, my translator had little time to do much more than learn her name and get her to lie down on the bed. It was a busy night.

So I busied myself with fundal heights and heart tones while he asked her more questions.

“Ask her how long she’s been sick like this,” I instructed my translator.
She responded but I couldn’t understand her words. She was slurring them.
“Is she drunk?” I asked again, confused and not a little worried, “Or has she had a stroke?”

The man who brought her in, didn’t know so he asked her daughter. There was a brief discussion,  during which it became clear that this man wasn’t her husband. He may have been a neighbor or a random stranger. But he wasn’t family.

“The girl says she doesn’t drink,” I was informed.

Angueth was barely hanging on at this point. Every few minutes she’d slip from consciousness and I’d try to pull her back.

Limp and cold, her extremities were swollen and her mucosa was white. She was severely anemic. I screened her for malaria symptoms.

She’d had all the major symptoms for some time, but she’d not been able to talk right for three days.

“This is outside of my scope of practice,” I explained to my translator, “Please get Dennis. I need his help.”

He grabbed the flashlight and left in a hurry, leaving me with Angueth, the Good Samaritan and a handful of kids.

Three to be precise.

Her eldest looked to be about 10 years old; the other two were both under 5. And all three sat quietly on the bench in the hall.

I continued checking her vitals while I waited.

Search as I might, I found no heart tones and eventually gave up. She looked to be about 7-8 months pregnant.

“My lower abdomen hurts,” she mumbled softly while rubbing the spot.
“Is it a contraction?” I asked in Dinka.
“Yes, it hurts. It hurts.”

Although I could not see or feel any contractions, I suspected her body might be delivering in an effort to save her life. So I did a vaginal exam.

Sure enough she was dilating. She was already 5-6 cm along.

Dennis arrived and I filled him in. He assured me that she hadn’t had a stroke but was in the late stage of severe anemia. Surprisingly her blood pressure was stable. So we started her on antimalarials and admitted her for labor.

Late as it was, there was no hope of getting her to Wau for a transfusion. Plus the Good Samaritan had quietly slipped away, and we had no way of contacting her family.

When I told her that she was very sick and was delivering early, she wasn’t surprised. But when I told her that her baby was no longer alive it took her a while to come to terms.

“So my baby is coming?” she asked, bubbles forming at her mouth.
“Yes,” I said looking at her full in the face. Her eyes searched mine in an effort to understand.
“When he comes. Will he be alive or dead?” she continued on.
“Your baby will be dead.”
Whimpering softly in response, she closed her eyes.

I think she wanted to say more, but the effort to speak was too great. Staying conscious was a hard enough.

Margaret took over her care in the night. She told me that Angueth’s labor progressed naturally, and a few hours later she delivered a girl. She was dead but hadn't been for long. Fortunately, Angueth lost only the slightest amount of blood, and her blood pressure remained stable throughout.

The following morning when I went to check on her, I was surprised to find her fast asleep. But when I tried to rouse her, she was completely unresponsive.

Although she’d been assessed shortly before by our night staff, it was clear the vitals were off. So I took them again. And sure enough, I was right.

She was unconscious and in shock.

With cold extremities, high pulse, and blood pressure bottoming out, I called for re-enforcements. First I called Tom, who listened to her chest for the sound of heart failure in the form of fluid build up. But eventually announced that it was out of our hands, saying she needed a blood transfusion.

Yes. That was clear.

Then I called Dennis, who helped me elevate her legs and suggested I give her Hemosele (a blood replacement IV fluid) to see if her blood pressure might at least stabilize. It was 68/42.

Blissfully unaware of the seriousness of the situation, two of her three children napped on our porch while the eldest went to get porridge.

When she returned I asked her to find an uncle or an aunt. Anyone. I told her that I needed to speak to them urgently. Could she do that for me?

Eager to help, she smiled sweetly and left right away. And I returned to her mother. I continued to monitor her vitals, but the fluids didn’t help.

Her blood pressure continued to plummet, and her breathing became more rapid and hoarse. A choking rattle filled the room as I watched... and counted. She was up to 60 respirations a minute.

A few minutes later, she passed away, shedding two tears without waking. They streamed down her cheeks and onto the bed.

Then the rattled ceased.

At the sight of her tear-stained face, I couldn’t hold back my own. And I mourned for this stranger as if she were my sister, grateful no one was there to watch.

A few hours later, Albino was able to track down her brother and uncle. They hadn’t even heard she was ill. Apparently her husband left some time ago. She lived alone.

Her family gathered around and I told them the story of her death. They were sad but thankful to have a few answers. Then one of our guards walked her children home while the rest of us placed her in the ambulance.

Rigor mortis had already set in.

As I helped lift her body into the vehicle, I had to step over two shovels and a pick.
    --How long will it take them to dig her grave?

Lord, please teach us how to do blood transfusions and send us the equipment. I’m tired of watching these women die for the lack of two liters of blood. Better still... Lord, send them to us for prenatals.

And if by some miracle any reader out there knows how to do transfusions and can teach us what kind of equipment we need, I want to chat! Write me in the comment section.

I’m praying that God will send us the equipment and the expertise to do transfusions. Will you pray with me?

Blood.

“Adut went to Wau and died,” Albino informed me.
"Adut?" I asked.
"The woman who needed the transfusion," he explained.
Albino is our compound manager and was the one who arranged for their transport.
He continued, “They were bringing her body back for the funeral, and their truck broke down. They want to use our ambulance again.”
“She died?” I asked incredulously.
“Yes. She died in Wau. They are stuck on the way back...”
“Did she get the transfusion?” I asked suspiciously. “Because had she gotten it... it’s unlikely she would have died.”
“I don’t know. I didn’t ask them,” he explained quietly.
“And what is going to become of the baby? Is there a wet-nurse in the family?” I persisted.
“I don’t know... I didn’t ask,” he repeated.
“Please ask them. I have to know...” I said, thinking to myself that I’d take the baby before they let her starve.

Mothers who die in or shortly after childbirth are trouble for the family. I’ve heard of more than one child left to die. I told this to Albino who nodded knowingly and told me he’d find out for sure.

That was two days ago.

Today Albino knocked on my door inviting me to go speak to the family. He remembered my offer to help if the family couldn’t (or wouldn’t) do it and wanted me to join him for a visit.

Eager to get the details of her care in Wau, I went with him. Sam, a Kenyan pastor on staff, joined us.

When we entered their bamboo gate, three men sat somberly beside a tukel and several sets of female eyes peered out at us from inside. Everyone was hiding from the mid-morning sun which was hotter than normal for the season.

The men didn’t rise to greet us, nor did they smile; the pall of mourning was heavy. They did shake our hands, however, and gesture to three empty plastic chairs. We sat down.

A long, respectful minute ticked by before Albino spoke. He told them we were sorry for her death and asked for details of their time in Wau. What had happened?

After a long discussion in Dinka, he turned to me to explain:
“She never got the blood,” he started, “They try to buy but there was no blood to buy. So, many got the test to see if they can give. They not have right blood.”

He paused to ask a few more questions, nodded as the husband explained, then continued:
“She had O+ blood. One man, he had same blood. But this man, he refuse to give. So she die.”

As he explained, my brain raced with this new information. I have O+ blood. I could have donated. Had I known, I would have given it happily. Why would that ‘man’ not give his blood? Why would he withhold what could so easily cure?

Albino then kindly asked them about the baby. I needed to know the child was well. In response, they brought her out of the tukel.

She was sleeping the deep sleep of baby-bliss. She knew nothing of the burial mound just 15 feet away --a mound topped with all of Adut’s worldly possessions. A worn out mattress. A green plastic basin. A cooking pot. Several dresses. A shovel.

As I looked from the child to the mound, I wondered what I’d leave behind if I were to die today. But I was quickly pulled from my reverie when Albino said my name.

“Stephanie,” he started, “they are giving the baby milk from market.”
“What kind of milk?” I asked. “Could I see it?”
They brought me a canister of baby formula and I asked them how they were giving it. What kind of water were they using? Were they giving it with a bottle or a cup? How many scoops were they using for the fluid?

Their answers were spot on; everything was being given correctly, and I was told that Adut’s mother (the grandmother) was now sole caregiver of the child.

As I looked at her thin, strong arms and grave but determined expression, I was comforted to see she was still young; she could be no more than 40 years old. There wasn’t a gray hair on her head, and only the slightest of crows-feet nestled in the corner of her eyes. The child would be well cared for and loved.

Albino suggested we pray before going, but I wasn’t ready. I wanted to teach them on how to prevent this from happening again. They agreed to hear me out and the newly formed crowd followed us to a shade tree outside their yard. 

We sat in a circle and I prayed silently to myself before I began; I didn’t want to mess this up. I don’t remember all that I said, but it was a lot.

I explained the role of good antenatal care in preventing such sicknesses and the importance of delivering at clinics. They listened with rapt attention, eyes never leaving my face. I had a captive audience and was grateful for it. Perhaps this information will prevent any more women from dying in their family.

The women sat a bit further back but were equally attentive. They didn’t fidget or cough. They hung on every word.
        --Lord, may all these women live!

After some time, I finished and Albino asked Sam to share the gospel. Sam spoke on the a verse in Isaiah that calls men grass (Is 40:6), reminding us all how fleeting and short life is. He encouraged them to place their faith in Jesus. Then Albino shared again.

I don’t know what he said but the crowd listened carefully.

Then the patriarch spoke. I never asked his name, but I don’t think I’ll ever forget his face. His dark blue jalibia stood out sharply against is cole-black skin. His piercing ebony eyes gazed fixedly on mine as he spoke. In them I saw pain and grief but no condescension.

His questions were honest --his pain real.

He spoke about the difficulty of being a patriarch, but he didn’t complain. Instead he explained how in the village when his daughter got sick, he had to take her to the witch-doctor first.

He lamented the social pressure he was under that forbid him from going to the hospital first. He added that in the village, when someone gets sick they must first find out if it’s a curse. So he took her to the witch-doctor.

Only when she didn’t improve did the witch-doctor allow them to bring her to the hospital. That’s when they came. But when they learned she needed new blood he finally understood. But by then it was too late. They weren’t able to get the blood.

“... had I known she just needed blood, I would have brought her earlier,” he explained, “But I was told she was cursed.”

My heart ached more and more with each sentence he spoke. Albino translated his words but the grief on his face needed no translation.

“Why is God letting all my children die?” he asked us. “It must be because He is far and does not know our troubles. He must not care...”

I listened carefully, thankful for his candor. Here was a man who really did want to understand. When he finished I asked for permission to answer his questions. Even though I spoke directly to him, everyone in the circle listened attentively.

Then I shared the gospel. I spoke about how his daughter was cursed, but not in the sense the witch-doctor suggested. She was cursed by sin. We all are. I explained that death was the consequence of sin, but that God had provided a way for forgiveness.

He listened carefully. Respectfully. They all did.

I gave them the clearest gospel message I could and we invited them to church. Afterward they thanked us for sharing this information with them. They had never heard these things before.

We prayed for them and left, shaking each one’s hand in respect.

As sad as her death is, I pray that it will be the start of new life for the rest of her family. Please pray with me that the seeds shared would find good soil and bring much fruit. Thanks.

Also pray for us to find a way to do blood transfusions. This is now the 3rd maternal mortality I know about that could have been cured with a simple transfusion.

Hemoglobin.

 

A month ago she gave birth at home to her second child --a girl.

Because of untreated malaria she was already anemic when she started to bleed postpartum. She bled a lot.

She bled and bled; but she lived.         --Barely.

A month ago she gave birth to a healthy child but she has been too weak to hold her. She nurses lying down between episodes of vomiting.

She is severely anemic; and the malaria that destroyed her blood cells still runs in her veins --a month later.

Only after her family realized she was at death’s door did they carry her in. Too weak to walk by herself, she stumbled in with two strong men holding her on either side.

Tom saw her and immediately recognized the signs. He started her on malaria medicines, blood replacement fluids, and tested her hemoglobin.

Not having a lab technician we were not sure of the results but they were better than nothing.

She was said to have a hemoglobin of 2.8 mg/dl!

A normal level for an adult female should be 12-16 mg/dl. Again... I suspect the reading could have been off a little (or a lot), as the person who did it is not professionally trained.

Regardless, she needs a blood transfusion.

Her family rallied and got money to pay for the fuel to Wau, and we took her by ambulance this morning. Please pray for her to get the blood she needs and to make a full recovery.

You may be asking yourselves why she didn’t come earlier for help...
I asked the same thing. As it turns out, she lives 5 hours away by foot. Such distances are not realistic for a woman in her condition. It took a month of family discussions and pressure for them to bring her. I’m so glad they did.

Please pray for her to live. Her name is Adut. Thanks.

Monica's Story

A picture I took of her shortly before her death... when I still hoped.

It was a busy clinic day with lots of preggos coming and going and two labors in various stages of dilation. So when a car pulled up I didn’t even notice.

But soon afterward there was a small tap at my door. One of the newest translators timidly informed me I had a labor. Sighing in mock frustration, I quickly went to meet my new labor at the clinic entrance.

Honestly, I was not ready for what I saw.

A small girl --looking no more than 12 years old-- lay pathetically against the entrance door. Beside her a woman with pleading eyes locked gazes with me; she was doing her best to hold the child upright.

“Is she pregnant?” I asked not believing someone so young could be ‘in the family way’.
“Yes, but she is sick,” one of the translators informed me.
“Bring her inside,” I said and quickly turned on my heels. I needed to inform Margaret of this new development.

Once we got her inside, I could see the small belly-bump low in her abdomen. Yes, she was definitely pregnant.

“How old is she?” I asked, trying to hide the disapproval in my voice.
“Fifteen,” I was informed by one of the many family members in the room. It’s as if half the village had entered my 10 foot by 12 foot cubicle.

“What are her symptoms?” I quarried while systematically checking her vitals from head to toe.

She was lethargic and barely able to stay conscious. There were no fevers and no reports of convulsions but I instantly thought of malaria.         --It’s always malaria.

Desperately fighting to breathe she gasped for air at the rate of 90 breaths per minute. That’s a breath and a half a second!

By this time Margaret had joined me and quickly looked at her eyelids to see is she was anemic.

“She’s a plus-plus for pallor,” she informed me then showed me her paper-white lids. I’ve never seen anyone so pale.

“She’s severely anemic,” I informed the family, “How long has she been like this?”

As we continued taking her vitals, the family informed us of the little they knew of her case. She was living with her uncle in Wau. Yesterday, she came home to be with her family. They brought her in to see us once they realized she was having trouble breathing.

“That’s it? That’s all they know?” I asked more than a bit confused. This girl has been sick a very long time. Why were they only now seeking help? I wondered. But that didn’t matter. Caring for her was what mattered now.

She measured to be about 7 months pregnant, but she could have been more. None of her family members seemed to know, and she was too exhausted to speak.

As I searched for heart tones with my doppler, I wasn’t expecting much. If this child was still alive, it’d be a miracle.
        --But I found none and eventually gave up.

How does a 15-year-old living in a big city get this sick? How?

After wavering back and forth on whether to give her IV fluids and consulting with the rest of the staff, we decided to test her for malaria. There had to be an underlining condition for it all.

She was positive. Malaria --that parasitic curse-- had struck again.

We gathered her family together and explained that she was desperately sick. She needed a blood transfusion immediately or she would die.

They listened.

“If she gets new blood she can recover,” I assured them, “But we are a small clinic. We have no blood here. You must get her a ride to Wau right now, so she can live.”

Four pairs of eyes searched my face as I explained. They could see she was dying. The only question was whether or not she could live.

“Get her a blood transfusion right away and she will live,” I went on. The steel in my voice was unmistakable but I realized I no longer felt the need to beg. They would either go or not.

Once I finished speaking the grandfather left without a word.

The girl’s mother and two aunts helped us to get her to the observation room and we started her on malarial medicines.                                  --I had hope.

Three hours later, her grandfather had (miraculously) returned with a car. I had even more hope. I even took a picture of her so I could ask you to pray.

Five minutes later she died.

She died with a few final gasps with her head on her mother's shoulder while her aunts prayed. One aunt left the rooms in deep wails. Another sat quietly knowing --too grief-stricken to speak.

They knew long before I would even admit it.

She was dead.

Dennis and Tom came to pronounce her because I was unwilling to admit it. I kept fighting for more hope. But in the end her heart just gave out.

Later on as the pastors came to minister to her family we learned more of her story.

The pastors praying for her family after her death.

Her name was Monica. She was 15 years old. She lived with her uncle in Wau. When she got pregnant out of wedlock he was furious and kicked her out of the home. She begged for months from friends and strangers. No one knows how she survived. When she got sick she had no money to seek treatment and no money to get home. Finally a stranger took pity on her seeing that she was very sick and let her hitch-hike back to Tonj. She died in our clinic the next afternoon.

She died of heart failure due to severe anemia caused by untreated malaria.

All of it could have been prevented had she known about us and come. Had she been able...

Pray that such senseless loss would end. Pray that we can find a way to get these women the prenatal care they need and deserve. Pray that no more 15-year-olds would be lost.

But just pray...

Mother's Day Message~

"Behold, children are a heritage from the LORD, The fruit of the womb is a reward."  Psalm 127:3

Guest Author: Suzy Kuj, IDAT Ministries Director
       Sitting under the grass banda to escape the horrendous heat in rural Tonj, South Sudan, I realized Mother's Day was here and I needed to appreciate my mum living now in Florida. More and more each year, I treasure my mum, who raised four children.  And each year, while working in South Sudan, my appreciation and wonderment is also for mothers worldwide and especially those here in Sudan.

      Our soon-to-be-independent nation holds one of the worst maternal mortality ratios in the world at 2,054 deaths per 100,000 live births. That means that 1 out of every 48 babies who are born alive loses their mother at birth. In the United States that statistic is 8 deaths/100,000, or 1 out of every 12,500. That the average woman in South Sudan experiences 7 pregnancies in her life makes this reality even more dire, statistically, 1 of every 7.5 women will die due to pregnancy or delivery complications. Take a moment to think of 8 women you know. If you lived in South Sudan, chances are one of them would die from hemorrhage, sepsis, or obstructed labor.

      It's a grim reality. So why tout these dismal maternal health statistics on Mother's Day? Because even in the face of seemingly insurmountable odds, there is progress, offering hope for South Sudan's future.

      Warrap County has only 10% of births attended by a skilled attendant.  Our clinic has a full-time African nurse midwife and a missionary midwife from USA even though we seriously lack available medical personnel.  Most health facilities in South Sudan are run by community health workers who have only nine months of training and few clinical skills to handle complicated cases, we have an American volunteer doctor and Kenyan Clinical Officer.  We are blessed more than others and have much to be thankful for.  Every day our clinic saves the lives of these precious women.  Our clinic also has JESUS!  And HE brings the greatest hope of all. 

Suzy with her children on Mother's Day.

     If you are a Mum, our Mother's Day gift to you this year is letting you know we commit to reduce the number of mothers who die during child birth, through using our trained staff and trusting in the Lord Jesus for hope.  We will work and pray so other children will have a chance to treasure their mums a little more deeply each passing year. We promise to bring the hope of Jesus Christ to each mummy and celebrate her choice to come to our clinic and allow us to help her.

Happy Mother's Day to all the Mum's reading this.

3 lbs of life!

Yesterday, just as the twin birth was coming to an end, I met two sorrowful faces in the hall. They rattled on and on in Dinka, and gestured toward a bundle one held in her arms. My translator was off working elsewhere, so, I  unwrapped the stained sheet to find a very small and very cold baby. 

She was obviously preterm. 

The woman holding her was old, wrinkled, and withered. Was she the mom? I couldn’t tell.

Once my translator arrived, I learned that the mother of the child died a few minutes after birth due to a massive hemorrhage. She had delivered at home, unassisted-- except by family.

Despite her prematurity, she was breathing well. Her vitals were normal, except for her temperature. She was 34.3 degrees (94 degrees Fahrenheit). I had to take it twice before I believed it.

The woman holding the child was the grand-mother, and she looked every bit the part. Thin, sagging, and with puffs of gray about the edges, she must have been 60 plus. (Mind you, that is NOT old in the States, but here, it’s ancient!)

She had already tied the band of cloth around her middle in mourning. (This, I’m told is done after a death to signify mourning.) It was her little girl that had died in those desperate bloody minutes after birth. She was sorrow edged in despair, and slightly splattered in hopelessness. So, I prayed for her. 

As I examined the baby, I wasn’t surprised to see she weighed only 1.4 kg (3lbs). She was thin and had frail bones. I almost feared moving her. (When I did a Ballard’s Score, she was only 30-32 wks gestation, or roughly 7 months.)

Since she was so cold, glacial really, I continued to monitor her while the grand-mother did kangaroo care. Fortunately, in the span of only 45 mins, her temperature stabilized.

She, also, sucked enthusiastically at the sugar-water we gave her by syringe. This was a baby who wanted to live. I kept telling them that, but they didn’t seem convinced.

When I told them, all they had to do was find a wet-nurse or get formula, and the baby would live, they argued with me.

I think they decided to bring the baby to the clinic to die. I really do. Every time I told them she would live, so long as they kept her warm and fed her properly, they’d shake their heads in disbelief. I was confused.

I called Sabet in for help. Was I misunderstanding? Did they want this baby to die? If so, give her to me! I’ll keep her.

He laughed at the impracticability of such a suggestion while trying to reason with the women. They were hopeless. They could see no way of helping her. They knew no one who could give this baby milk. They had no money for formula. (A month’s supply of formula costs roughly $12 or two and a half days salary.)

They refused to go home. The grand-mother explained that she didn’t want to be there to watch her child’s burial. (I couldn’t figure out why, but I didn’t try to, either). She asked to stay at the clinic, and seemed to indicate that she’d stay until the baby died.

The problem was, the baby wanted to live. She had no infection, no signs of distress, and now her temperature was stable. All she needed was food to live. Wouldn’t they go talk to their family about feeding her?         -- No. We’ll stay here until she dies.

I went back to Sabet. I wanted to take the child from them and strap her to my chest. I wanted to feed her myself and help her live. Why were they giving up so easily?

Part of me understands that grief played a role in it. Another part of me imagined their confusion. I’m sure they have never seen a baby so small and frail, live before. They must have thought I was crazy for suggesting she would.

After Sabet spoke to them for the second time, he agreed that the women were planning on letting her die. So, he promised to get them formula if they would just feed her. They agreed.

Explaining the details of how to mix formula correctly took time, but I think they got it. They also promised to bring the baby back for check-ups. I’ll let you know how it goes.

Please pray for them all. Pray that this little girl gets the food she needs to not only survive but to thrive! Pray that as she grows, the family would see what a precious miracle she really is! God has put air in her lungs and life in her body; He has a beautiful plan for her life! May she one day grow to know His love! Thanks.

By the way, they named her ‘Akec’, which means ‘born to a dead mother’. 

Postscript:
During our conversations, I found out the the woman who died was apparently very sick all throughout her pregnancy. The family said she had 'yellow fever', but everyone claims that; it’s rarely the case. The symptoms they described were stomach pains, swelling, and green eyes. I think she may have been anemic, due to some underlying chronic liver problem. That is the best explanation I can come up with for her hemorrhage, and subsequent death. But then again, I’m guessing. They said the woman who died was seen only once, and that was at a different clinic. They told her she didn’t need medicine, and sent her away. Pray that the women of this community would all come for prenatal care, deliver at the clinic, and seek postpartum care. Pray that one day the name ‘Akec’ would never be given again. Thanks.

Waiting to die...

Preparing the vehicle to transport her.

I have a story but I don’t want to tell it. I’m afraid if I write it down, it will somehow become real to me. It is true though and that’s why I don’t want to tell it. But the not telling is starting to make me sick. So here goes...

Monica was a regular prenatal patient. Each time she came, I stressed the importance of delivering with us. She also knew not to push longer than two hours at home for I taught it many times. But as a 19 year old Dinka girl expecting her first child, she was at the mercy of her family when it came to how she’d deliver... not her midwife.

When her labor started, her family chose to keep her at home calling for a TBA (Traditional Birth Attendant) to watch her through the night. By morning, even though she was fully dilated, the TBA wasn’t able to get the baby to come down. She pushed for hours causing the baby’s head to swell as well as her labia. The TBA did all she could but eventually gave up.

Precious time lost.

But instead of coming to us next, they gathered their money and took her to a witch doctor, where (I’m told) he massaged herbs on her belly and proclaimed that ‘Now, the knots were untied and the baby could be born.’ Realizing he had nothing left to offer, they finally brought her to us.

More time lost.

When she arrived, I estimated she had been fully dilated for at least 6 hours, possibly longer. Her contractions were still strong but there was absolutely no progress. She lay exhausted, writhing in silent pain as her family explained all they had done. 

As I did a vaginal exam, I knew immediately she required a cesarean. There were too many signs of obstructed labor. This couldn’t be fixed by binding her belly. This wouldn’t progress if I stretched her and forced her to push. This appeared to be a case of deep transverse arrest (when the fetal head gets stuck in the mid-pelvis, restricting the mechanisms of labor). So I told her family she needed a cesarean. They didn’t seem surprised.

Fortunately, both Monica and child where doing fairly well. All we had to do was get her to Wau and they could be saved. There was just one catch, night was falling. Buses don’t travel at night. However, even if it were broad daylight, they’d be out of luck. With all the voting this week, the buses were booked solid. Even if the family paid twice the fare, there were no seats available. So I went to Sabet and asked if we could drive her.

He was happy to comply but we had to find our diver first. It’s dangerous to drive at night but sometimes if he is in the right mood, and you ask him nicely he will take that risk. We sent people to find him.

More waiting.

The family paced the floor while she writhed in pain. I went back to Sabet an hour later asking if we found our driver. He explained he couldn’t locate him and that we’d have to wait until morning. But even then, they wouldn’t leave at first light since the truck would need to be fueled first.

Meanwhile, the family told me they had arranged for a motor bike to take her home. What? I was confused. “How will she get to Wau if they went home?” I asked naively. Only then did it occur to me that they were giving me an out. They wanted to take her home to die.

The last time I had this conversation I kept telling the family that the patient (a multigravida with  IUFD and potential placenta abruptio. Her story here. And here.) needed to get to Wau or she’d die any minute, thinking that pressuring them would get her there faster. It didn’t. It just made them insist she go home and die there instead. The family gave up because I painted such a dark picture.

So this time, I played my cards differently. I reminded them that Sabet had promised transportation at sun-up. All they had to do was get through the night and we’d drive them to Wau. I explained that both she and the baby were alive and they shouldn’t give up hope.

They were glad for the news. But it meant more waiting.

My stomach churned as I considered how long she’d have to endure. Already, she had suffered so much. I couldn’t help but marvel at how she handled the pain. But her silence wasn’t courageous resolve for her eyes betrayed her. They darted from face to face in panic. Fear had it’s grip on her. So I prayed.

I prayed she would be able to handle the pain, that the contractions would stop, or that miraculously the baby would be born. I prayed that if not, she’d make it to Wau and both would be saved. I entrusted her to God and went to sleep. The on-duty health worker would check on her in the night and alert me if there was a problem.

Tossing and turning all night, I got up early to check on her. I needed to be reassured. I arrived as the health worker was unsuccessfully trying to find heart tones. It was apparent Monica hadn’t slept at all.

I shooed away the onlookers as I searched for heart tones myself. Nothing. Her abdomen was taut and tender to the touch. How long had she been like this? The health worker explained he never checked on her in the night. What? I wanted to scream it but didn’t want to cause a scene.

“What do you mean you never checked on her? You were suppose to check her every two hours. I left very clear instructions.” He stammered something about not having been told, refusing to look me in the eye.

I was kicking myself for not waking the guard to let me out of the compound that night to check on her. I should have been more persistent. I shouldn’t have trusted our health worker with something so important. I was mad at him... myself... and the situation.

She was in shock. Her blood pressure was bottoming out. It wasn’t good. On top of it all, her baby was dead. I couldn’t find a heartbeat anywhere. I called for Dennis to help me get an IV started as her veins were collapsed. He got it on the third try. Then I went to wake Sabet.

I explained that the baby had died in the night and the laboring mom couldn’t wait any longer. She was in shock. We needed to go now or she’d be dead too. He immediately got on it, saying he didn’t realized she was at such a risk. An hour later they were on the road.

In my head I imagined they’d drive up to the hospital, rush her through the doors and take her directly to surgery. She’d be saved.                       But I was wrong.

Our driver returned in good spirits saying she got ‘a picture taken of her baby on the inside’ (ultrasound?) and it was still alive. (Really the baby was alive? How?) He added that the ‘doctor lady’ said Monica would be observed for another 8 hours. If she didn’t deliver in that time then they’d do a c-section that night. (What? She is being made to wait another 8 hours! $#@%$#!) I wanted to scream.

I bit my tongue instead and smiled as he gave me this ‘great news’. My gratitude was genuine. I was thankful he was willing to go, for Sabet’s generosity in sending the vehicle, for the family’s continued hope. I trusted that the doctors in Wau knew what they were doing. I trusted God with her life. It didn’t make sense to wait. She had waited long enough but it wasn’t up to me. (By the time she arrived in Wau, she was fully for over 24 hour.)

So I waited and prayed. More time lost.

The next day I learned that she got the cesarean after failing to progress in Wau. She waited 7 hours before they took her in. The baby was born dead (not a surprise) and an hour post-op, she joined him. I don’t know why.

I think it was all the waiting. 

Her death surprised me -- not because dying in childbirth isn’t possible but because it was completely avoidable. I know it’s foolish to play the ‘what if’ game but I can’t help it.

What if she came to the clinic earlier?
What if they hadn’t wasted time pushing so long?
What if they bypassed the witch doctor?
What if they arrived before sunset?
What if our driver was found and took her to Wau that night?
What if the hospital rushed her to surgery immediately?
What if... What if....

Update: Blood Transfusion?

A few weeks ago, I wrote about an 18 year old pregnant woman who had a hemoglobin of 4.4 after a case of severe malaria. We attempted to do a direct blood transfusion to improve her condition. (Read her story here.) But we failed. We just aren't set up for this kind of thing.

In fact, after several hours and many 'learning curve' situations, we were only able to infuse about 30-40 ccs of blood. She spent the night at the clinic and we discharged her to Wau the next day, so she could get a transfusion there.

Well. Today I learned she died.

I was surprised to think a grown woman could die for something so preventable, let alone a pregnant one. What happened? What went wrong? Didn't she go to Wau? Didn't she get the blood transfused?

One of our translators, Wilson, (who happens to be her cousin) told me the rest of her story today. She was too weak to travel so he (Wilson) went to Wau instead and inquired if there was any blood available. He was told they had no B+ blood but if someone came in to donate they'd do the transfusion. He came back, told his family the news and together they stopped trying.

She died two days later. (Three days after our attempt at a transfusion.)

I asked him why the two men (that we cross matched to her in our lab), didn't just go and give their blood; They still had plenty. He looked at me confused and said, "But they had no blood. Don't you remember? We couldn't get any from them."

Instantly my heart sank. Yes, I remembered. But I remembered it much differently than he did. We couldn't get blood from them because we didn't have the correct materials -- not because they were out of blood. (!#$%!@!)

I asked him if he remembered learning in class that a person has over 5 liters of blood in their body on average. He nodded and said he remembered. "Well, if a person has 5 liters, don't you think that they can give much more than 30 ccs?" He just cocked his head to the side and looked at me sadly. He didn't appear to understand.

"Wilson, your friends still had blood to give. She could have gotten the transfusion with their blood." I struggled to keep the incrimination out of my voice. He explained that the 'Fathers' decided that they shouldn't give anymore since they had tried and failed...

I tried to teach him more about how blood transfusions are (normally) done and how much can be given. I didn't want him to feel bad, just to know so this didn't happen again. But I cut my lecture short, seeing he wasn't listening.

He was tired. He was sad. He had done all he could... all he thought best in fact. So, I shut up and started lecturing myself instead. "He did everything he knew to do... He was trying by going to Wau, by talking to the 'Fathers'. He was fighting for her life and failed... just like we did."

The conversation moved on but my heart sank further down. What more could I say? I failed.

I failed to explain to them that a person cannot 'run out of blood'. I've failed because... this isn't the first time I've heard this excuse. I just never thought it could hurt anyone.

Generally when someone says they have 'no blood', I ignore them. I don't try to explain to them that it's impossible to live without blood, that we have liters and liters of the stuff... yada yada. I just move on with a prenatal or check-up or whatever. But now I see the damage this ignorance can do.

Another face of maternal mortality. Another needless death. Lord please don't ever let this happen again. May her death teach me to teach them better. May I never forget this lesson. Amen.

More than a statistic....

 (Warning: this story speaks of death and maternal mortality.)

Early Monday morning, I was called to attend a young woman in labor. It was her first and she was scared. As I checked her in and listened for the baby’s heart tones, I could hear a patient in the other room trying to breathe. A wet, gurgly rattle of a sound filled the clinic, distracting me. I pushed it to one side of my brain and refocused on my labor.

Her name was Debora and had been coming for prenatal care for months. I got her situated and set up for the birth. Everything was going smoothly, so I thought I’d sneak in a bit more sleep. She was only 4 cm and had three doulas monitoring her every move. I wasn’t needed just then. So, I told the health worker on shift, James, to keep an eye on her and call me if anything changed.

But before I left, I couldn’t help but peek in on the patient in room one. What was causing all that noise? James followed me into the room and showed me her chart. A man, somber and tired was holding her in a semi-recumbent position. She was unconscious and had been that way for over a day.

As I read her chart, I was startled to learn she had delivered two days before. A stillbirth. She immediately got sick and passed into a coma. They waited a day before they came for help. But by then, there was little we could do but watch her struggle to breathe.

And struggle she did. Foamy saliva formed in her mouth with each breath. She was drowning. An older woman sitting by her side, kept wiping it away. Brow knit in desperation, she studied me as I studied her chart. Dr. Tom had seen her. He had done all he could.

I went back to bed but her death-rattle haunted me. I couldn’t sleep. Questions kept taunting me. What had caused her baby’s death? Why was she unconscious? Why did they keep her at home so long? Would she live? No answers came.

It was only a few minutes later that I heard James knocking on Tom’s door across the compound. Murmured whispers exchanged. Doors opening. Gates slamming. Something told me she had died. I got up and James confirmed it. She had stopped breathing. The fight was over.

I wanted to go to the family but ... I also wanted to hide. What did I have to offer this family's grief? I tried to go back to sleep but God kept insisting. “Go now. Go talk to them,” He whispered. I obeyed but my heart in my throat. What could I say?

When I got there, I found the patient covered from head to toe in a blanket. The man was gone but the woman still sat by her side, hands clenched and pale. Tearless, she sat shaking uncontrollably and searched my face for answers. I called James in to translate and sat beside her. I asked her if I could pray for her. She nodded, still shaking.

As I took her hands in mine and prayed, my heart broke. This precious woman died in childbirth. She is the face of maternal mortality. A statistic -- but oh so much more! She is a daughter. A wife. A sister. A friend. Her motionless body, hidden under the blanket, couldn’t hide this fact to me.

Her name was Abuc.

After praying, I asked the woman to tell me her story. What had happened? She hesitated only a moment, then spoke for sometime without pause. My translator listened, nodding encouragingly for her to continue. This is the story she told.

Being of age, her daughter was married earlier this year. But her husband caught her cheating with another man, who impregnated her. Understandably upset, he retaliated by putting a curse on her and the child. This was the result of that curse, she explained. First the child died and now her. She added that this was her only daughter and she was too old to have others.

-- “How long was she sick?” I asked.
-- “Four or five days. She delivered a dead baby two days ago and then got really sick.”
-- “Did she get prenatal care?” I couldn’t help but wonder if this had been preventable. What medical reasons caused this death? Was it preeclampsia? Hypovolemic shock? Malaria? Pulmonary embolism? Stroke?... What?
-- “Yes.” She explained. “She went once to the clinic in Malualmok.” (A small neighboring town.)
-- “Only once?” I asked. She nodded.
-- “What was she complaining of before the birth?”
-- “Headaches, neck and joint pain. But that is all.”

That means it could have been anything-- malaria or perhaps preeclampsia. I couldn’t say for sure. The fluid in her lungs made me think it was a pulmonary embolism. I wanted to grill her with more questions but I didn’t have the heart. She didn’t need answers. I did. She already knew why her daughter had died. She was cursed. So I dropped it.

We sat in silence. Nothing more needed to be said. I wanted to ask her if she knew Jesus but her grief was so fresh. So I sat and held her hand instead. Her shaking slowly subsided and together we waited for the men to return. They had gone to get transportation. The body needed to be buried.

They returned with more men to help dig the grave. Abraham, a family member, asked in perfect English if we could drive them back to Malualmok. I got Mike (our compound manager) and he agreed to take them. It wasn’t even light yet when they drove off with her body.

I couldn’t get her out of my mind but I had to. Debora needed me. Turning my attention to her, I was happy to watch her labor so well. She handled the pain with slight moans, walking the baby down. She was tired but healthy.

In my mind, I couldn’t help but compare these two births. Both were first time moms in their teens. One had come for prenatal care for months, taking vitamins and getting her shots. The other was seen only once. One had delivered a stillbirth at home. The other was delivering with me in the clinic. Her baby was fine.

Later that day, Debora delivered a gorgeous little girl while surrounded by friends and family. It was beautiful watching her go from girl to woman; from pregnant to mother. And best of all she lived. I’m not saying that had Abuc come to deliver with me, she would have lived. I will never know that for sure. But I do think her chances would have been better.

Was her death preventable?

Pray for Abuc’s family and the superstitions that plague these people. Pray for these women to come for prenatal care and to deliver at the clinic. May there be no more preventable maternal deaths. May it stop here! Now!

Culture Matters: Why maternal mortality is so high....

Not long ago, a friend posted an article on the realities of maternal moralities in developing nations on her blog (Midwife to the World). Each time I read it, my heart sinks and my skin grows cold. It is true -- horrifyingly true. I saw this happen in the Philippines and I know it happens here in Africa.

Please read the story of Mrs. Y and you will see what I mean.

May this NEVER be true of our clinic!