Maternity Ward Observational

During my two week stay at the maternity ward as a clinical instructor, I had the opportunity to note some interesting cultural observations.

Day after day, I'd arrive at the maternity center with students in tow to find a number of first-time mothers in labour. Usually, the first-time mothers laboured the longest, while the multigravidas (aka: women pregnant for the second or more times) came much later in labour.

One G2 (aka: mother for the second time) came striding in, calm as the sea after a storm, only to discover she was fully dilated. She delivered (to my and my students dismay) while we were out of the room. It took her less than five minutes from beginning to end.

But labours like hers were not the norm. Most of the women who laboured and delivered there were first-time mothers-to-be. They arrived after the first or second contractions and then stayed until the baby was born.

For some this was quick. However more often than not, they were there for the long haul. One young girl (having more than likely braxton-hicks contractions) had arrived three days before. She had not had contractions in over two days, but she was not discharged nor did she seem interested in leaving. For the life of me, I am not sure why.

Several women came in at 1 or 2 cms dilated and chose to stay. The maternity ward was bustling but they did not seem to mind. They waddled around and watched as others delivered around them one by one.

When it was their turn to push, they were watched as well.

A lot of the first-time moms had hypertonic (aka: abnormally strong) contractions even though they were only 2 cms dilated.

After talking with the staff about it, I discovered that it was common for women to try and induce labour by drinking traditional herbs. These herbs cause painful and frequent contractions that don't always dilate the cervix. I saw similar things in the Philippines.

One nurse tsked their use of herbs, explaining that usually the ineffective contractions led to exhaustion, an inevitable referral to the hospital, and an (avoidable) cesarean for fetal distress. 

I also saw things done by the staff that caused me to pause.

One nurse sutured a woman up without using local anesthetic. Naturally the woman cried out in pain with each stitch. Meanwhile the nurse yelled and berated her for making so much noise. I didn't stay to watch. I couldn't.

One day while evaluating one of the labours, I noticed her family had purchased cytotec. When I asked her about it, she informed me the nurse had insisted she buy it. The nurse denied this since she was already well advanced in labour. However when I inquired the woman's family about it again later, they presented me with the prescription the nurse had given her. I never saw what the nurse did with those drugs but they were certainly not for the woman who purchased them.

I also saw a nurse be given a 'gift' of a capulana (a traditional cloth) at one point. She hurriedly rushed to put it away in her purse as the gift-giver went back to her friend in labour. I had been told that such 'gifts' were expected by the nursing staff but I confess I was still disappointed to see it.

Stitches?

The third birth I observed seemed normal enough to begin with. The mother was 27 years old and expecting her second child.

When we arrived, her contractions were strong and frequent but she seemed to be handling them well. Within no time, her water broke displaying a yellowish puddle of meconium stained fluid.

The nurse set up the room for the birth (which means she got a bed pan, some non-sterile gauze, and a birth kit and placed it at the foot of the bed). The bed pan was slipped under the mother's bottom and she was told to push.

She pushed for only 5 minutes for the head to be born. But then the nurse reached in and wrenched him out. The mother stayed quiet while the nurse literally pushed and pulled and twisted and turned his little body every which way imaginable.

Two minutes later, the nurse lifted his body free of the mother with a gush of more mec-stained fluid.

The nurse then injected her with oxytocin to precipitate the placental detachment, then started massaging her uterus.

She massaged and pushed on it externally until 4 minutes postpartum it popped out in a gush of clots and blood.

She placed the boy in his mother's arms and evaluated her tear.

There was a tear but it was not deep. At most i would have put it at a shallow 2nd degree. However, as the nurse considered it, I overheard her worry how she was 'out of stock'.

I thought nothing of it, until a few minutes later I watched her suture her up with 3-0 acrylic (aka: non-absorbable) suture material.

She placed interrupted stitch after interrupted stitch, burying the deeper stitched beneath the more shallow ones.

My jaw dropped in surprise and my legs snapped closed in horror... but I didn't say anything. How could I?

We were guests there. I could not make those kind of calls... nor could I criticize them in their work. But I confess, I worry still what those buried sutures might do. Perhaps her body just rejected them and the string fell out as they healed.

That is my hope at least.

Fit To Be Tied.

The next birth happened a day or so later.

The young mother-to-be was alone but apparently unconcerned by this fact. Not all of the labours have companions.

So as she laboured, I taught the students how to evaluate her contractions and take her history. She was 20 years old and expecting her first child.

She readily admitted to taking traditional herbs to prepare her body for birth... and even to start her labour.

Since her contractions were strong and frequent, the nurse decided to do a vaginal exam at 10 am. The nurse was VERY aggressive during this exam, manually dilating her cervix despite the patient's vocal protestations.

Afterward the nurse informed us she was 90% effaced but only 6 cm dilated. But after such forceful manipulation of the cervix, I did not think it true for long.

Sure enough, an hour later her water broke and she immediately got pushy.

In fact, there was no stopping her. So we called for the nurse. 

The young mother was already fully dilated and wanting to push. The nurse tried to get her to focus and push effectively but she would have none of it.

All she wanted to do was scream. 

One scream was so piercing and so long, it could have shattered glass.

After some negotiation, we convinced her that screaming like that was not actually helping. In her defense, she did really try to push. But each time she did, she would close her legs and withdraw.

It was going no where. 

The nurse was not pleased and she argued with her.

She then tried to push again but ended up kicking the nurse and swatting her hands away.

The nurse was even less pleased with this behavior. 

After more negotiating, the young mother confessed that she needed help controlling herself and requested that two of the male medical students hold her down while she pushed.

Yes. She wanted them to forcibly hold her down so she would not hit or kick the nurse.

So they did.

Mind you, they seemed more than a bit surprised by this. I don't think either one of them woke that morning thinking that they'd have to tackle a pregnant woman while she pushed her baby out. But you know... some days are surprising like that.

I soon found myself out of my depths and stepped away from the melee to watch at the foot of the bed. The remaining two students shuffled a step closer to me with each new scream. One (who plans on being an obstetrician) was wide-eyed and mesmerized by the beauty of it all. The other (who is unlikely to choose obstetrics as a specialty) kept hiding her eyes and furtively glancing my way for assurances that the woman was not in fact dying.

Meanwhile the young mother continued to scream and abuse the staff while pushing. The nurse, more than likely frustrated with the abuse, decided to perform aggressive perineal stretching. The baby was born quickly but caused a significant 2nd degree tear in the process.

The placenta was pulled from her body within minutes of the birth with strong cord traction. It was so strong in fact, that the cord snapped, squirting blood all over the foot of the bed.

The nurse decided to suture the tear before presenting the baby to the mother. The young mother screamed and fought the sutures just about as much as she did the birth, despite being anesthetized.

When the nurse finished up the stitches, she reached down for the baby's ankles, lifted her high in the air and presented her genitals for the mother to see.

The young mother whispered, 'a girl' to herself and smiled.

Then the baby was taken off to be wrapped and weighed.

Normal?

Her contractions were strong and frequent when I first met her. She lay on the bed and her mother held her hand.

The pain contorted her face and forced the occasional groan, but she didn't seem to notice it much. For the most part, she was surprisingly quiet.

So quiet in fact, that I didn't think she was even close.

As a 17 year old G1 (aka: primigravida or woman pregnant for the first time), I expected things to go a little slower. But her body had other plans.

Shortly after we arrived, her waters broke and she started getting grunty. One of the students informed the head nurse, who started setting up the room.

She started pushing before the nurse was ready, so I encouraged her to breathe through contractions and taught her how to push effectively.

The grandmother, looking a mixture of exhausted-relief, excused herself to the corner of the room and said nothing. Absolutely nothing.

The mother pushed effectively despite the five extra medical student faces huddled around her bed. She didn't seem to notice or care in all the pain.

The nurse on duty expedited the birth by doing perineal stretching and the mother remained silent. She pushed only a handful of times before the head was born. The nurse didn't wait for the next contraction, she just reached inside and wrenched the shoulders free. Again, the mother made no noise.

The baby was out less than a minute when the cord was cut. She too made not a sound. Just like her mama.

The nurse grabbed the child by both feet and swung her in the air, presenting her upside down for the mother to see. The mother smiled when she saw it was a girl, then dropped her head back on the bed in a rush of exhaustion.

The nurse lay the child on her breast and it mewed quietly.

Within 3 minutes after the birth, the nurse aggressively massaged the mother's uterus and applied traction on the cord. The placenta wasn't budging. She forced it harder and massaged even more aggressively.

This continued until the nurse found herself with a torn placenta (only 5 minutes postpartum) and decided to do a manual extraction. Reaching her right hand in up to her elbow, the nurse extracted chunk after chunk of the placenta from the uterine wall. Each time she reached in, she came out with chunks, clots and membranes.

The mother made not a sound. 

Afterward, the nurse reached in repeatedly with non-sterile gauze to evacuate the uterus and vaginal canal of any remaining blood. But still the young, new mother remained silent.

Inside, I screamed for her. Inside, I cried out in pain.

For her.

How she remained so stoic... so quiet, I'm still not sure.

As I looked through the nurses' bloodied hands, several baffled expressions caught my eye. "What must these medical students be thinking?"

For many of them, this was their very first experience with birth. I shuddered to think that this was considered 'normal' in Mozambique.

Perhaps... it is normal. 

Multiparity

The last two weeks of May involved teaching at a maternity ward downtown. My job was to help introduce fourth year medical students to 'normal' birth. Much of our time was spent labour watching, timing contractions, evaluating fetal heart tones, and palpating fetal positions. However, we also got to do a number of newborn exams and assist in a few births.

One day we arrived to find a young woman occupying one of the labour beds. Naturally, we assumed she was pregnant (as her fundal height was marked), so I told two of the students to time her contractions. Ten minutes later when I came back to see how things were going, I was informed she was not in labour and that her babies were in the other room.

So I instructed them to get her obstetrical history instead.


The new mother explained that she was a 20-years-old mother of six. Earlier that day, she had delivered twins at home. She came to the maternity ward for the birth certificate but did not seem very interested in any other service. Since her babies (a boy and a girl) were cold and covered in sand, the nursing staff had taken them for evaluation and placed them in a warmer.

The mother explained that she had delivered her first child at the age of 11 and that her previous four pregnancies were simple. This was her first set of twins, however. 

She didn't want to talk much about the particulars, so we didn't press her for more information. Although I know 11-year-olds can get pregnant, my heart hurts to think that this mother has so many mouths to feed and so much responsibility...  at such a young age.

What were you doing at the age of 20?

Teaching

As I mentioned previously... during the months of April and May, I was invited to be a clinical instructor for a medical school in a neighboring city. The people I met and the opportunities this experience afforded me were equally wonderful and heartbreaking.

The first four weeks, I worked with nursing students doing clinical rotations in a busy hospital. The school gave me a white coat, a pen, and pointed me to the various departments. I was working in the pediatric department and the malnutrition center.

Needless to say, what I saw was...

Stressful: Each morning I had to rush from where I was staying (my commute was anywhere from 40 to 90 mins one-way) to get to the hospital in time for roll call. The hospital was crowded. The needs were overwhelming.

Disconcerting: The manner of teaching was very different from my own (educational) experience. I felt like I was wading eyebrow-deep in murky waters for the first few days. Every day brought new challenges with no cultural insider to ask if I was making a fool of myself or standing tall. Sigh.

Heartbreaking: No one forgets the gaunt and wasted face of a 8 year old boy dying of AIDS. It's hard to silence the wails of a mother who just watched her two year old die.

Fascinating: One day a 4 day old neonate was brought in to determine the sex. The genitals were ambiguous. After the examination the doctor explained the mother had an hermaphrodite. The news was not well received.

Overall, my time there was...

Exhausting: Most days turned out to be 10 to 12 hr days. Speaking all day in Portuguese was a challenge as well... mentally and physically.

Expensive: Though friends let me stay with them for free, the public transport was either cheap or inconvenient. Getting back and forth from work took an hour and a half in the morning if I went with 'cheap' (costing less than a dollar). But if I needed to get there quickly (30 minutes or so), it cost 8 dollars. Sigh.

Insightful: After two years of stories about policies and practices in governmental hospitals, I was finally able to see first hand that they are true. I saw corruption, neglect, abuse, and incompetence. But I also saw many who did not fit the mold and strived to do well.

Blessed: I was able to make lots of new friends and learn how the medical system works in this country. Often I was impressed by the caliber of medical professionals in this country despite the obstacles they must face to care for their patients.

Invitation to Teach

You’ll be happy to know my mud-encrusted toe nails are bright and shiny again. It’s amazing what a tepid bucket bath can do for the spirits!

I don’t remember ever going so long without a shower --when one was available, that is-- and I can only attribute it to my muddled mind and burdened heart. I forget to do things like eat and shower when I’m tied up emotionally.

To say, I’ve had a lot on my mind lately would be inaccurate. ‘A lot’ indicates more than the usual load. What word describes more than ‘a lot’?

A ton? A mountainous weight? Atlas’ burden?

No. That’s not accurate either. Because it’s the number, not the weight, of the issues that trouble me most these days.

As I sit and type, I’m reminded of one of my dad’s favorite sayings: ‘If it’s not one thing, it’s another.’

So yesterday I shared about one of the things. In the days to come, I’ll be sharing even more. I’m finding it’s remarkably helpful to write them down.

The simple task of typing them out reminds me of catching butterflies. I bounce after each thought in my head, trap it with a gossamer net, and gently pull it free. As I examen the specimen, I marvel at its intricate markings.

So delicate. So beautiful. So distracting.

I lay this butterfly aside and it stays... remarkably.

And I pick up my net for the next.

So... as every good story needs a beginning. That is where I’ll start. Here goes...

While in Maputo for my paperwork a few weeks back, I stayed in a missionary guesthouse where I met a missionary couple from Beira. They were leaving to come back North the same day as I was and I asked to hitch a ride. They kindly obliged.

This lovely couple shared their stories with me as we traveled and we told them of my plans as well. We discovered that we had similar interests.

They work with the youth near a Catholic medical school in Beira. Many of their Bible study students attend the school and over the years they have made many friends there. They offered to connect me with their friends.

When they dropped me off, I promised to stay in touch and come visit at the first opportunity. I wanted to meet with the school directors to see if they would send nursing or medical students as volunteers once the clinic opened.

About a week later, I was able to arrange the trip out there and I called them up. They generously invited me to stay the night. However the day I was to head out, I got delayed and called them to say I’d be running a few hours late.

-- “Hi, B. So sorry but I won’t make it for lunch,” I explain by phone. “I’ll see you later in the evening. I had an emergency to take care of this morning... and I’m delayed”.
-- “Oh, dear. But we arranged for you to have a meeting with school director at 2pm,” she worried aloud. 
-- “What?” I stuttered. “Um.... thanks. But had I known I would have tried harder to be there. I’m three hours away.... I don’t think I can make it in time.”
-- “Oh, dear. But they can’t meet tomorrow....”
-- “I’ll try to come now. Please see if you can push it back a bit.”
-- “Okay. See you soon.”

As I made a mad dash back home to pack and raced off down the road, I couldn’t help but be simultaneously confused, irritated, and thankful.

• Confused.... because I had no idea about the meeting and was surprised. 
• Irritated... because I was now late for a meeting I never knew was happening and I might not make it in time.
• Thankful... because they had made such a sweet effort to bless me.

I was three hours away. The meeting was to start in three hours exactly. By the grace of God... I made it.

I had just enough time to park, meet up with my friends, then hurry off to the medical school. They tried to catch me up as we walked.

We arrived and I shook Dr. E’s hand with a smile.

-- “Hi”, he smiled back. ‘We are excited to have you here today... but before we go any further we need to know what kind of midwife you are... and whether or not you expect to be paid?”

I shared my experience with him a bit confused and denied any interest in payment. In my head, why would they pay me to send me interns? I shrugged it off and let him lead the conversation.

He was pleased to know that I didn’t need payment and offered to introduce me to the woman in charge of the nursing department.

I confess, the meeting was one big confusion. There were three languages being spoken simultaneously and questions that didn’t connect with my expectations.

Forty minutes later, I was sitting around my friend’s dining table sipping coffee and trying to make sense of it all. As I strung all the questions together in a play-by-play evaluation, it occurred to me that the meeting felt more like a job interview than anything else.

So I asked the obvious.
-- “Was that a job interview?”
-- “Yes, it was. What do you mean...” he asked in confusion.
-- “But I thought the meeting was so I could ask for volunteers... not be one,” I explained.

This revelation brought on more confusion, prayers, and phone calls of explanation. I called Dr. E to apologize for the miscommunication. He didn’t seem to mind at all and insisted that they could really use volunteers.

Although I no longer saw the reason for another meeting scheduled the next morning, he didn’t want to cancel it. Rather he asked me to come and hear them out about what volunteering would be like.

The next morning I went and met several doctors and directors. They told me they had teaching modules and I could be a huge help in two modules in particular and that I’d be useful as a clinical instructor for both the nursing and medical department.

If I agreed, I’d be teaching students three days a week in the morning and my afternoons could be spent working in their HIV department where I could learn the country’s protocols. This is a HUGE answer to prayer. I know I’m hopelessly uninformed on HIV protocols and treatment options (there was almost no HIV in S. Sudan), but I wasn’t sure how I’d be able to learn them... until now.

Needless to say, I told them I’d pray about it and get back to them.

That was a week ago.

Since then, I’ve talked to my director here at Maforga and he agrees it’s a God-opportunity. Moreover, God has provided a place for me to stay while in Beira and the right uniform. I’m only missing white nursing shoes.

If all goes well, I’ll tentatively start next week. However, that depends on my car working. Since my return from Beira, it has started overheating.

I’m hopefully getting it fixed today. Pray that it can be sorted quickly and that I can volunteer without any issues. I’m eager to see what God has planned for this new adventure.

Preaching in Pinayanga.

After I first arrived in Mozambique, I was having dinner at a missionary-friend’s house and the topic of Simply the Story came up. I was naturally enthusiastic having just come from another training (before I left the States) and I was discussing how it’s used for oral learners.

My friends (and missionaries from Australia), Roger and Amanda, were curious but hesitant to hear about another teaching method. Didn’t Africa have enough of them already?

I insisted it had its place and offered to show them how it worked sometime. Roger, who teaches pastors in the villages, listened but made no indication that he’d be interested.

Nevertheless, part of his pastor training curriculum focuses on various types of teaching methods. So in an effort to teach the pastors a more oral way, he invited me out to teach. Attendance was not mandatory since it was a ‘special feature’ of sorts, but I was thrilled at the opportunity all the same.

When I prayed about which story to share, God led me to the story of Jesus calming the storm and the waves found in Mark 4:35-41.

I prepared by testing it out on a few missionaries at Maforga a few days before, and I prayed.

A lot.

The village in which Roger teaches is called Pinayanga. You might remember that Pinayanga is also the village I visited last year when I discussed the possibility of teaching their girls nurse-midwifery. (You can read that story here and here.)

When the Pinayanga villagers learned that I was coming, they remembered me and were eager to have me come. I suspect most were eager because of medical questions, but, at least for now, they were going to get a STS story instead.

In preparation for the teaching, Roger arranged two translators (one to speak for me, and one to speak to me). I tried to explain to them what it would entail but some of it was lost in translation.

Early Monday morning as we drove to the village, Roger tried to lower my expectations.

-- “I don’t want you to get your hopes up,” he warned. “This group doesn’t participate much.
-- “Oh..?” I said softly then waited, seeing he had more to say.
-- “Yes. I cannot get them to answer any of my questions. They only like to listen and they won’t ask questions. It’s the way they learn in school here,” he continued.
-- “Okay.” I answered slowly, adding optimistically. “But perhaps with this style, it will be different...”
He glanced at me sideways as if to say he knew better. But didn’t say any more.

"Ultimately," I thought to myself. "God would speak to them through this passage or He wouldn’t. How much they answered didn’t matter." So I continued.

-- “If they don’t answer... then the teaching will be very short,” I added matter-of-factly. “Anyway... it’s more the chance to practice and learn, right?”

He nodded in agreement, and we continued to drive in silence.

I, however, continued to pray. I’d seen this teaching method bring crowds alive with discussion and was eager to see how these villagers would respond.

But more than anything, I anticipated good things.

For God is good.

We didn’t have to announce our arrival. The minute our shiny black SUV drove through the main square, people started making their way to the church property. Within a few minutes we had about a dozen women and children, and a spattering of men.

Apparently, most of the pastors had in fact decided to take this day off.


When we walked into the church there was a young girl waiting for us. Sitting slightly slumped on the church bench this girl moaned to herself in pain. Her mother stood behind her propping her up.

It was clear she was burning up with fever.

Malaria.

She’d been this way for two days.

I asked a few quick questions about her status, then we laid hands on her and prayed. Her mother thanked us then placed her on a blanket in the back of the church.

I couldn’t understand why she was not getting any treatment. So I asked.
-- “Isn’t there a health post here?” I asked her mother.
-- “Yes, but the guy who runs it left for the weekend (which was 2 days before). He won’t arrive until this afternoon.”
-- “I see.”
-- “Can’t you buy the medicine in town?” I asked.
They nodded a clear yes, but then didn’t explain why they hadn’t.

Was it from lack of money? I didn’t think so. A few paracetamol are not expensive.

Then why?

I never got my answer.

The young girl moaned and slept while the rest of the learners arrived. And turning my attention for the girl, I happily joined the women all the while testing my new language skills and taking pictures.

They were thrilled to see their faces in the display screen on my camera, but many squinted in blurry disinterest when it came their turn. I couldn’t help but wonder how much sight rested in those clouded windows.


As more women arrived, I was informed they ‘needed’ pictures as well and I happily snapped off a few more shots.

The colors and layers were fascinating.

Beautiful.

Not long after, Roger called us in and the story began. My translators struggled at first but quickly picked up on what was expected of them.

The crowd had grown slightly and was then roughly two dozen strong. More men had snuck in towards the back. Plus, a number of breastfeeding mothers had gathered as well, rocking and swaying their babes as they listened.


Telling the story was easy enough. My translator had memorized the story in preparation. But Roger was right, the minute I went to ask them a question... they turned their faces to the floor so I wouldn’t call on them.

However, with time and a little encouragement, the answers started coming. First tentatively, then in full force.

Roger watched in surprise as one after the other stood to answer and throw out his or her ideas. Soon, it became a lively conversation.

There were some cultural snags nonetheless.

For instance, I could not get them to think of how anyone could have done anything different in the situation. (For those familiar with STS, this was the ‘choices’ question.)


Also, when I suggested that anyone could have done something ‘not quite right’, they argued with me saying, “No. They could not have done that. That is not possible.” The only way we found around this was by discussing ‘failure’ to do what was right. Only then did they understand and concede the possibility.

Later, Roger explained that many in church believe that one must never speak of their own failures in public. Instead, one must only speak positively.

I suspect this has something to do with the widely held belief that evil spirits are always listening, and that some things should never be spoken out loud. But that is just a suspicion.

Alas... I have much to learn!

I won’t go on and on. But know that the day was a huge success. At the end when I applied the lessons we had discussed, immediately the group came up with examples of those lessons.

One by one, they stood to testify of how and when they had clearly obeyed God and yet had still had massive spiritual attacks, and how God had gotten them through it by His power and love.

It was amazing!

So. Much. Fun.

(Happy sigh.)


They invited me to come back and teach on a Sunday morning in a few week’s time. This has to be arranged of course, but I’m excited at the possibility. Please pray with me as to when and how this might happen.

Thank you!

Common Knowledge.

Some days teaching is a blast. Some days... not so much.

I've been teaching our health workers to count fetal heart tones and take pulses. Simple stuff, Right? I thought so. But it isn't getting through. Today I asked one of them to count a woman's respiratory rate for 15 seconds. But after waiting a good minute he still wasn't done. I figured he was just losing count and restarting. Then I thought... maybe he thinks he needs to count 50 seconds not 15.

I asked, "You know you only need to count 15 seconds right?" Yes. He says. He understands... only 15 seconds. So he does it and comes up with 75. What?

I tell him that's impossible. She'd be hyperventilating. So I ask him... you do know what 15 seconds means, Right? He just cocks his head to the right and looks at me.

Then I grab the clock and point out 5... 10... and 15 seconds on it. Then the lights turn on! OOOOHHHHHHH!!!!!! So that's 15 seconds!

Huh?

Then he proceeded to count for 10 seconds. I showed him again. 5... 10... 15.... Let's try again. By the third time he got it.

I'm not saying he isn't smart. He's one of our best health workers. I'm saying, I have to remember that what I think is common knowledge isn't here. I keep forgetting that.

Most of the women I treat don't know how to read let alone what month it is. Many of the health workers we are training have only gone up to the 5th grade in school. They are very smart men... just not educated in the same what as I was. Sigh.

Lord may I have patience to train them properly and always remember that common knowledge isn't always so common in Sudan.