Thank you

From Tina, Sarah, Carole and Jody:

Please accept this huge thank you to everyone who supported us to and through this amazing journey. We are all extremely grateful and touched to have had the opportunity.

Thanks to all the donors and helpers and knitters and crafters and advice-givers and drivers who did their part to make this journey easier on us and gave so generously to the moms and babes we were so lucky to support.

We attended hundreds of women and helped over 150 babies into the world. Thank you.

A huge thank you also goes to our fearless leader, Cathy and her amazing crew of preceptors/life coaches/travelling companions who also gave of their time and energy to walk along side us through the maze of international health and childbearing. And they did it with grace (literally), and empathy, and kindness, and humour, and generosity. Thank you.

And thank you to all the Ugandan health care professionals that allowed us onto their wards and into the reality of their experience. And to the Ugandan drivers and hotel staff who looked after us during our time there.

And, although I write this at the behest of Tina and Jody and Carole, I would also like to thank them, personally, for being so amazing. I am jealous of the many lucky women who will have one them as their midwife over the many years of practice to come.

Thank you. Thank you. Thank you.

Sarah

The faces of "Maternal Mortality"

I am back now, in Canada, in the arms of my family and have some final reflections to share - written on the plane back from Uganda.

We are so separate from maternal death in Canada. In Uganda, it is a tangible spectre that haunts everyone involved. The staff, the women, the families.

We say in Canada that our biggest goal is "healthy mom, healthy baby." In Uganda, it is "live mom, live baby."

On our way to safari, we chat idly in our Canadian way, trying to build some camaraderie via reports of our terribly busy and important work. Our tiredness and hard work is constantly commented on by the hotel staff (who are up long before we are and work late into the night, long after we are in our beds).

We say to our driver (because we are headed on safari and we feel we deserve it. We work so hard, we see unspeakable things, we crave a swimming pool and a change of scenery)... we say we have "had a hard week. A mother has died of bleeding after childbirth."

Our driver says "yes, that happens here. That is how my wife died. Five years ago."

We die a little inside.

"I am so sorry"

"It's okay. It's okay," he says, going to fill the safari van with diesel and rocking the van to get the tank really full.

We sit with our hearts beating, the weight of reality pressing down on us.

It's not f---ing okay.

Of course not. But he is okay. He survives. He has not taken another wife because his children are still too young, he feels, and a stepmother will mistreat them. But he hopes for another wife one day. Maybe four.

I picture the woman who works at the hotel working the buffet. One day, I see her half-hidden behind the pillar, picking up one foot, and then the other to relieve the tiredness. I'll bet I sit more that she does in my daily work.

She is a sunny person. I often catch her quietly watching us. watching me, smilling at our banter and jokes. "You are well?" she asks. "We are burungi!!" [fine]

One evening she comes to our table. Sadness roles off her like fog. Carole says "are you okay??"

She pauses... it hangs in the air. Says ".......................no" and steps back just a little. It's that moment where you ask someone how they are and the surface cracks like glass at your tone or your body language and you get a painfully honest answer.

"My sister died."

"Oh no, I am so sorry"
"What happened?"

"Hypertension"

I look at this young woman standing beside me.

"Was she...pregnant?"

"Yes"

"Oh. no.
"Does she have other childen?"

Turns out her sister was 33 years old, leaving three older children and was buried on Sunday.

The connect is lost and she backs aways from the table like a ghost and doesn't meet our eyes for the rest of the night.

We feel the weight pressing down on us and look up pregnancy-induced hypertension in our texts at the table.

Thinking "....... Why?"

Why are they crying?

On Canada Day, we saw a woman take her last breaths.

We went to Lower Mulago with our Canadian flag pins on our chests (over the heart) [nothing seems to make you more patriotic than being away from home]. I have a bad feeling in my stomach (not related to unwashed produce) but to Cathy saying earlier that something bad usually happens on the last day on Lower Mulago.

As we walked into the room, these two non-ugandan students are sitting by the door on the bench. "oh my gosh - are you from Canada?!"

We are and they are - they are pre-med doing overseas observational placement. The purpose of observing escapes me somewhat. The only thing that keeps me sane here is knowing that at the very least I can do SOMETHING.

They chat with us and say that the woman in the first bed has lost some blood and they are looking for blood for her. She is lying with her eyes shut, breathing evenly. I don't even notice that the baby is there, lying at the foot of the bed.

So, to make and long, sad story shorter and no less sad --- she very quickly goes very downhill and dies. They can't take our blood, even though they ask for special permission. It is too late, anyhow.

I wrap the baby boy with Jody in one of our donated blankets - hating that this is the story of his birth, hoping he will be okay.

I keep myself busy the only way I know how, by working, and managing to choose the most complicated woman to help. The one who refuses all vaginal exams, the one who has not been examined in 2 days of attempts. The one whose full, full bladder is not only palpable but visible from 20 feet away.

She tells me that men have damaged her, that the doctors damaged her, that she was beaten by her mother, that it happened many years ago, that it was in the last 2 days. I do a vag exam with my pinky only (seriously) - which tells me that there is a head, low, and no cervix at the front. That's it. That is all that she can take. I do a cathetar with super sonic speed for the full, full inital bladder. She pushes for an hour, about as long as Cathy says we can let her. She is okay with me, says I am a kind one - then tells me that she will have a ceasar if I do it only, that no one else can touch her. Shit. Not going to happen. There is meconium now draining with the amniotic fluid. Shit. I ask for a consult, and the consultant does the first full VE on her (she is fighting and refusing and crushing my hand) and there is caput and mec and she is on the list for section. I am relieved, because as much as I wanted this to be a healing birth for her, the writing is on the wall. The fetal heart is consistently good. 130 140 130 150 140

I do a 2nd cathetar with super sonic speed - to prep for the inevitable surgery. That 2nd cathetar drains red bloody urine. Shit.

The soundtrack of our day is the weeping and wailing of utter grief from the dead woman's family. Desperately sad and angry tones echo and the rain pours down like tears.

She asks me why those people are crying in the hall and in the breezeway.

"Why are they crying?.... Did they lose their baby?"

"I don't know," I say, " Sorry, I can't understand what they are saying"

She listens carefully and quietly. I think she has forgotten about it.

Then she says:

"I know! They are crying because Michael Jackson has died!... I, too, am sad."



I spent hours with her, and left her, prepped for surgery, next on the list to go, with a good fetal heart rate. That was all that I could do. Sometimes that is all you can do.

Childbirth Numbers Uganda style

Rural hospitals here have like 20 births a day. Many rural hospitals in BC have 20 births/month.

Mulago hospital does like 120 births in 24 hours. Crazy.

In Mulago, we have had two sets of twins in the same day. In Masaka, we have had 3 breeches in the same week.

We now all have our numbers to “graduate.”

Although, technically, I do also need one more continuity of care. Which my husband kindly reminded me when I was "mentioning it." Thanks, honey.

We have seen so much here and been with so many women in labour -- women of every circumstance.

Women with large, supportive families, and women who have nobody. Nobody.

I have supported women who were accountants and teachers and also women whose occupations were listed as:

-"peasant"
-"housewife"
- and my favorite...... "hawker"

I have supported women who were closer to my children in age, than to me.

And I have supported women who were prematurely aged beyond what I would have thought possible. Aged by hardship and poverty and hard physical work and personal sadness.

I have supported a Gravida 10, Para 9, through a safe birth and to a healthy baby, only to find out later that 5 of her other children had died in early infancy. And this baby was now back in to the hospital, admitted to the nursery and very sick.

So many stories.

HIV testing

I went to antenatal and learned about HIV testing. The tests are like pregnancy tests and give results in 30 minutes. In Kampala, I watched as the blood samples from 7 pregnant women and their 7 husbands were tested. I watched the control lines turn and saw 13 negative tests. And one that was positive.

The positive was one of the women and her husband was negative. I talked to the lab tech about what they do. He retested the husband and wife’s samples with all three of the available types of tests. She was confirmed as positive and he was negative. And sitting right outside. Waiting.

The system is that the couples or women arrive, are interviewed for a health history, go to a pre-test counselling session, go to the lab for the HIV blood draw, wait for the results, go to post-test counselling to receive the results, then go get palpated, get their BP taken and then go.
It was a cruddy feeling knowing that someone’s life was about to change forever. But better to know. And the perinatal period is a window for accessing women for testing, and a critical time to know status for reducing mother to child transmission.

As I went back later to show Carole the lab, I saw an increasing pile of test strips on the counter and on one perforated card 5 of 10 tests were positive.

“You do not have this struggle in Canada”

“You must clearly label the husband and wife’s tests as you do not want to give the wrong person the disease.”

Bad Moment

I was at the high risk ward at Mulago Hospital with Jody and Angela (preceptor). The obstetricians were just doing Rounds with the Residents and medical students. There were about 6 of them grouped at the end of one bed. They finished with that mother and casually said "We can't hear the fetal heart, but it doesnt mean the baby is dead. The head is right there. She will deliver soon." I asked one of the Residents if I could try to detect the fetal heart with my fetoscope (can usually pick up sounds better than the pinard that is used here in Uganda). He said sure and I grabbed my fetoscope and went back to the bed. As I got there, I realized that the mother was silently pushing and the baby's head was already partially out. I called out "Help, somebody,the head is right there." The group of doctors at the bed right beside me didnt even turn around. I was not gloved, had no ties, no cloths to wipe baby dry, no razor, no oxytocin. I was telling the mother to "TOE SINDACA" (DONT PUSH), and managed to get my gloves on (at least one hand double gloved). Jody and Angela were trying to get on gloves - they had been putting an IV into another woman. I guided the little body out and knew right away he wasn't breathing. I was calling for help, and the group of doctors still didnt turn around. One man glanced over his shoulder as my voice got more urgent, and then turned away. "We need a resus here" I told Jody and Angela. By then, they were there, with the few very important items we needed. I cut the cord and Angela and Jody ran with the baby to the resuscitation room. Despite 10 minutes of positive pressure ventilation and chest compressions, the little boy never took a breath, never had a heartbeat. They had to come back and tell the mother, who sobbed and sobbed. The doctors never looked at her again. I was so very angry. It was said best by one of the head obstetricians at a meeting we had been at another day - Doctors here must start treating EVERY woman like their relative if there are to be changes in obstetrical care here in Uganda.

Tina

The Other Side of Working in Uganda

Many of you tell us you have been keeping up with our posts so for those of you who have, you will know we have tried to mix up the things we've posted. We have funny posts, descriptions of Ugandan life and lots of birth stories. It is only now that I feel like I can post on my reflections on the harder side of working in the free hospital in an undeveloped country (if you like that term)in a major city.

Birth here for the most part happens well, narcotic free, and both mother and baby are okay - particularly in Ward 14 where we work. This ward is considered low risk and it is staffed exclusively by midwives. There is no obstetrician, no operating room and no pain medication. We have worked for 6 weeks without instruments and often we do not have supplies first thing in the morning (with shift change). But since we travel with our basic supplies (gloves, medication etc...) it is rare that the what we need is not available at all (its more likely they are in safe keeping for a "real" emergency).

Sometime though, this isn't the case. Like the day we walked in to the high risk labour room and a mother, who had bled for hours after delivery, took her last breaths. Sarah and Cathy had the same blood type and offered to do a transfusion but it was too late. I wrapped her baby while the rest of our team helped with the mom. Minutes later we could hear the yells of the family outside - which continued for what felt like hours. Someone commented that luckily the baby was a boy - if not the family might have chosen not to take the baby home.

The next day Tina and I went to rounds and both of us felt the impact of hearing that the mother's death could have been prevented. Perhaps earlier action? but at the very least just getting her a blood transfusion (the hospital was out of her blood type). This would not have happened at home.

The other part of our work that I find most troubling is seeing babies born to ill (e.g. malaria in pregnancy) or malnourished moms. In our country again this normally doesn't happen. Where it does, a care provider often will have "caught" the problem and supports can be put in place. Here there is no one who is consistently able to help other than family, if they can afford it, and it seems most women coming to the busy free hospital are from families who are not able to help.

One recent example is Fatima's baby. He was born earlier this week and Tina and I happened to be hanging around for the birth - another medical student was catching. When he was delivered he needed to be resucitated and had many other problems. The next day we found out he needed an ultrasound that the mother could not afford. So Tina and I paid 10,000 shillings ($5 USD) and he is now being referred to a specialist. If the specialist recommends follow-up tests or surgery what will happen to that baby? Will the family be able to afford to get him care?

The reality here is much different in many ways and yet the experience of birth in Uganda has touched me not only in these ways but in the same way birth does at home. The strength of the women and their resilience is truly inspiring. Each birth brings learning to my life, joy to my heart and peace to my soul. I hope in some way the moms and midwives I worked with in my time here understand how much they have given me and I hope I have helped in some little way to make their journey better.

Jody