Ode to a Midwife

At the end of September, I was informed that my friend and mentor of 30 years had been hospitalized in the ICU. This was not a huge surprise since she had stage 4 colon cancer for the better part of the last 2 years and had been in and out of the hospital several times over the last 4 or 5 months, although she had never been in the ICU before, so I had a bit of a sinking feeling. After a few groggy telephone exchanges, Cynthia told me she was being put into hospice, they had told her she had perhaps 4 months, and she was going home in a day or so, as soon as they delivered the hospital bed. She asked if I could come and be there with her and help with her birth center, which was on the ground floor of her house. So, I packed a bag and drove down to Wisconsin.

The hospital bed was delivered the next day, a Friday and was set up in the living room which had a beautiful view of the many acres Cynthia lived on and of course, the sunrise. About an hour later, an ambulance arrived with an all-female crew and Cynthia in tow. We no sooner got her settled in the living room when, true to form, she immediately started dictating who should do what and how and one of the first orders of business was getting her a glass of wine. This should not surprise anyone who knows Cynthia. She wanted to have a big meeting about dealing with the birth center, clients due beyond October and what the plan was moving forward and this could not be accomplished without wine.

The logistics involved in finding care for all the clients of a very busy practice that served a large Amish community, was a bit overwhelming. I committed to being there to attend the 5 women that were all within the window of their birth time, 37 weeks or less. Cynthia would also need someone there 24/7 with her, so I could easily do both things. Her daughter lived over an hour and a half away and worked fulltime. She was able to come some days after work and be there on the weekends, or at least this would be the plan.

It was apparent from the get-go that Cynthia had no plans to start the process of dying. She made copious phone calls over the first few days to let clients know the show would go on, (much to the dismay of her daughter and me) although there was no possible way she could attend a prenatal visit, let alone anyone in birth. She could not use the stairs and she was in a good deal of pain, even with the pain meds. Her daughter and I exchanged more than a few glances of frustration. I had never seen anyone more determined to stay in this realm than Cynthia.

Saturday evening when the first client called and said they were in labor and coming to the birth center, I readied myself. When we heard them arrive, Cynthia was sitting on the edge of her hospital bed with wide eyes and a determined look and said, “I have to go down there”. I looked at her and said, “I know you want to but there is just no way you can ever make it down the stairs, it’s too much. I know this is hard. I have it covered. I’ll keep you posted and I’ll let you know how things are going”. This did not stop her from texting me every 5 minutes for the 30 minutes it took the client to birth her beautiful little girl. The Amish always make birth look easy.

Cynthia was already drifting off to an exhausted and opiate-induced sleep by the time I went upstairs. But I recounted the birth, minute by minute with as much detail as I could remember and saw her face soften as she imagined the scene, a scene she had lived thousands of times over in her 54-year career.

For people who never had the pleasure of knowing or even meeting Cynthia, it needs to be said that she was an incredible force in the world and especially in the birth community. Her wisdom is legendary and so is her reputation. When I first met her, 30 years ago, she told me she was a pariah. She told me I would be judged just for being in her orbit. But I knew a wise-woman when I met one and if she was willing to teach me even a fraction of what she knew, I was willing to be an outcast along with her. Even now, now that I have caught up to her in terms of ‘numbers’ of births attended, I still learn from her. She was hands down the most knowledgeable and skilled midwife by far, that I have ever met. She was also quiet humble and despised any kind of notoriety. She was a traditional midwife in the truest sense of the words and served families and had no other agenda than to meet women where they were in their process and honor their path and respect their autonomy.

I learned the finer points of breech birth from her. I learned when to intervene and when to sit back. I learned that women who had had multiple cesareans could indeed go on to birth vaginally as long as they had the right support for their birth. I learned the nuances of attending sets of multiples and I learned how to stop postpartum hemorrhage with no medication at all. Cynthia was a gifted herbalist and knew plants inside and out. Native American on her mother’s side Cynthia’s maternal great-grandmother was Cherokee and this is who she first learned midwifery from when she was just a girl. She managed her first postpartum hemorrhage alone when she was just 14 years old.

So, it isn’t a stretch to say that Cynthia’s entire life was dedicated to midwifery. Even through a stage 4 cancer diagnosis when most people would say, it’s time to pack it up, Cynthia didn’t miss a beat. She continued to attend births. She had surgeries and she had weekly treatments. She continued to take clients. One of her last phone calls was with a woman due in March of 2023 and she told her to come for a prenatal visit the next day unbeknownst to us until the woman showed up for a prenatal visit! We had to apologize and turn her away.

When Cynthia spoke, people listened. Her voice was deep, strong and commanding. She hated appearing vulnerable in any kind of way. She had a confidence about her that took people aback at times. I saw this with the hospice nurses that came to visit. Under no uncertain terms would they be telling her what was about to go down, she made it all too clear just who was in charge of this show. After the first nurses visited for the initial intake, I walked them downstairs and out the door. I said, “Congratulations, you survived your first visit with Cynthia!”. They laughed uncomfortably and got in their car and drove off.

So, when only 2 days later, we called one of the nurses to come back to the house for a pain management consult, she was quite shocked to see a very different Cynthia. Over the 2 days since the last visit, Cynthia had made calls to clients, discussed what medications she did and did not want to take, talked about how she would have no trouble driving again once the back spasms went away, got up and cooked for herself and even fed us! She talked about plans in the spring and she had me transplant her spider plant because the pot was too cramped. What she didn’t do was talk about dying.

I have been with quite a number of people now in varying circumstances during their transition at the end of life. It is so incredibly different for everyone. The process itself is intense, curious, beautiful, strange, daunting, and wonderous. You can’t help someone die any more than you can help someone give birth. All you can do is bear witness, hold space and be there for that person in the way they need you to be which may not necessarily be the way you want it to be. You need to meet them on their terms. It isn’t about you.

A corner was turned on that Wednesday afternoon and I called Cynthia’s daughter to come to the house. Although the nurse had increased the pain meds when she visited, we were up all night with Cynthia who was in a great degree of pain which distressed us so much because it was so unnecessary. Her meds were increased and changed again and finally she was no longer experiencing that kind of pain or agitation. After that, neither of us ever left the house again and Cynthia’s son and grandchildren, some whom were out of state, were called to come for the weekend. It was apparent to us that the 4 months was a rather optimistic prediction on the part of the doctors.

Cynthia was an intensely private person throughout her life. It was no different at the end. She did not want any visitors other than her family. She did not like appearing vulnerable in any way. We had to turn people away that came to the door. In light of that, as much as I want to share some of the more intimate details of this time and her process, they are not mine to share. So out of respect for Cynthia and her family, what I will share is my experience from this time.

Once the family had gathered, I did my best to spend as much time downstairs in the birth center as possible to give them space. However, I was the one in charge of giving her meds, which happened every 1 to 2 hours around the clock, so I was upstairs a great deal. Still, it was a beautiful gathering, and I could feel the love and joy with everyone around, cooking, talking, eating and drinking. They graciously included me and I felt close to them as if we had always known each other, which was good because we were all walking through this together; this incredibly intimate and sacred journey that so few people in our society get to witness anymore. But this is how it should be and this is what Cynthia wanted and it was awe inspiring. I have so many more things to say about this beautiful family, each one of them individually, but I also want to protect their privacy.

On Friday evening, one week after Cynthia had arrived home, another client went into labor. She too came in and birthed within 45 minutes. By this time, there was another midwife who had come from out of town to be down in the birth center so I could attend to Cynthia. Still, I went down and attended the birth and when all the work was done, I went upstairs and after the 1:00am meds I sat next to Cynthia and told the birth story right down to the number of pushes and the weight of the baby. She could still hear even if her responses were minimal. It was always Cynthia’s wish that she die like her great-grandmother who attended her last birth at the age of 97 and went to sleep that night and never woke up again. This was not to be but that didn’t mean I couldn’t do my best to approximate it.

The irony of the whole situation was not lost on me. Welcoming life into the world while simultaneously bearing witness to a life leaving the world. It was an experience, a incredible feeling – the privilege that I felt straddling both ends of the spectrum in this manner was indescribable.

To honor Cynthia’s Native heart, the family built a bonfire on Saturday evening and played drumming music to usher in the full moon that was about to appear after midnight. We all knew this would be the time. It was a cold, crisp, clear night. Everyone was in bed by 1:30am and I came up for 2:00am meds. Cynthia’s daughter was on the sofa, half awake. I asked her if she needed anything, she said she didn’t. I gave that round of meds. I had noticed through the course of the day the difference in Cynthia’s pulse and breathing. I knew it wouldn’t be long. And for all the resistance she showed in those first days home, she was now exhibiting a gracious surrender to the process, just as I imagined she would.

At some point just after 3:00am, with the full moon shining in through the window, my mentor, my teacher, my friend, made her transition to the next place. The stillness in the room was so apparent. It felt so empty. Her presence, larger than life even while dying, was so palpable, that once she took her leave, her absence was profoundly felt.

During the week when all of this was taking place, there were so many things going on behind the scenes. Mutual friends of ours were texting me, supporting me from afar. I did not ask permission to use names, but they know who they are. C, L, DA, B, J, D, V, all of them midwives, all of them midwifing me though this experience. I am so grateful for every one of them. Cynthia had given all of them had a tiny piece of the puzzle, which we realized later once we all put it together.

L told me that Cynthia had called D to come and help with births because she knew if D came, she would want to move back and take over the birth center. That is exactly what happened. B told me that Cynthia had told her a while back, she wanted drumming when she was transitioning. I told this to her family, and we made it happen. We would not otherwise have known. Cynthia did not speak to me at all about what she wanted during her transition so I could only piece things together from the tiny bits she gave to other along the way.

I never had any profound bedside chat with Cynthia during her process because that was not how things unfolded. Everyone thought there would be months, I think, so we were all operating on that assumption until we weren’t. And she herself was not in a place where she wanted to discuss it. But on one particularly lucid conversation over the phone from the ICU, before she came home, she started telling me how far I had come from when she first met me. How I had come into myself, found my feet and what a presence I was in the birth world and how proud and how happy she was for me. I realized later; these were things she needed to tell me. This had been the bedside chat. They were not necessarily things I needed to hear, although it was nice to hear them. She always worried about me just a little bit. She needed to reassure herself that I was going to be okay without her.

It was that conversation I realized, looking back, when she chose me to walk her home. She knew intuitively that I was up to the task. She knew I would care for her family in the way she wanted – that I would be unobtrusive and respectful. She knew how vulnerable she would be and that I would protect her. She knew I would have her back, whatever that meant and whatever it came to. She knew I would advocate for her if it was needed, and it was, and I did! She knew I would see her on her way with grace, dignity and respect just the way she did with the thousands of women she served. She knew she had taught me well. Of all the things I learned from her, of all the gifts she gave to me, this last one was probably the greatest.

The Last 8 Hours

I have been home from South Sudan for nearly 6 weeks. It has taken me all this time to write about my end of mission (EOM) primarily because it has taken all this time just to process those last hours. I was already suffering from pretty severe burnout and vicarious trauma but the last hours really upped it to a whole different level.

I really wanted a simple EOM day. I would wake up in the morning, have my coffee and then just spend the morning bidding farewell to staff, get in the truck around noon and go to the airstrip. I was still on call (by choice, never wanting to miss a thing!) and as luck would have it, at 3am the national staff midwife called me on the radio. He said there was a patient who had come in complete and birthed twins immediately upon arrival very quickly one right after the other. She then hemorrhaged but now it was controlled and they were just informing me, she was stable.

I was not asked to come to maternity but knowing I should have been called as soon as the patient arrived, regardless of how quickly she was birthing, and then should also have been called when she started bleeding, I felt a need to go down there and just make sure all was indeed well. This decision would prove very critical later.

When I arrived in maternity about 5 minutes later, I found the 2 staff midwives standing at the patients bedside. There was oxytocin in an IV running and the patient was resting on the delivery table. They again said she was stable. I checked her fundus, it was firm and there was no active bleeding at that time. I looked at the blood in the bucket and estimated there was about 2 liters. This was a very significant amount of blood. I asked what her vital signs were. Not only had they not taken them, they didn’t have either a BP cuff or pulse ox in the room! I checked the conjunctiva and saw it was white and asked what her hemoglobin level was – they had not taken it. At this point they jumped into action and took her vitals and tested her hemoglobin. She was found to be in compensated shocked based on her vitals – BP 70/40, pulse 142 and a hemoglobin of 3. She needed a transfusion immediately.

I asked the midwives to get the family to go to the lab so they could be screened for blood donation. This is the only way people can get transfusions, by having family donate. We have a bank but there are usually only a few units and we still need to replace it.

While that was happening, I asked them to put an IV line in her other arm as we would need a second one. I asked if she had been given misoprostol (a medication we use to help postpartum hemorrhage (PPH) and to prevent it as well. They had not so I asked them to do that. In the meantime, I was checking her fundus again to make sure it was staying contracted and several clots came out and then she started to bleed again. It was a fairly substantial amount. I kept massaging her fundus while I had the staff taking vitals and getting the oxygen tank. This was not going well. It went through my mind that I was leaving the project in about 8 hours and this patient was going to die.

I called the expat midwife that was to replace me, while I controlled the bleeding, we needed more hands. Once she arrived, we basically took over the care of the patient completely and the staff got blood from the lab and we hung it. The patient was going to need at least 3 liters and 2 immediately but we needed to get the donor blood and that would take time, so we started with one liter and hoped it would make a small dent. Shortly thereafter, she started bleeding again, it was terrifying. I got no distal pulses and she started gasping for air. Again, for the second time, I thought she was going to die. I called the MD on call and did bimanual compression to help stop the bleeding. I asked the staff to give 1 gram of tranexamic acid (a drug used to stop bleeding in traumas). The MD arrived and I briefed her. There was nothing I expected her to do other that what we were already doing and she was not an OB but because I thought the patient might die, I wanted as many expats there as was reasonable. I did not need to carry this alone and I didn’t want to be questioned later as to why I did not call for support.

By 6am I was able to go back to my tukul and have coffee and pack the very last of my things. I was ready to leave on every possible level. I still needed to to carry my radio because it was how the radio room would reach me to let me know when the truck would take me to the airstrip. As luck would have it, I was called by the in-patient department (IPD). They had a 32 week pregnant patient admitted for GI bleeding and now she was bleeding vaginally and they wanted me to come and assess her. I called the national staff midwife and asked him to meet me in IPD with the ultrasound. I arrived at the patients bedside and while I waited for the ultrasound to arrive, I checked the patients labs. I noticed her hemoglobin was 5 and her platelets were 7! These labs were from the previous afternoon! I asked the nurse if anyone had pointed out these abnormal (life-threatening!) labs to the MD or anyone! They said they didn’t know – this was not my staff so I was unsure how this department ran. I called the MD on the radio and asked him to come.

The MD and I agree if the patient started bleeding a third time, we would call the surgeon and take her to OT, her uterus would need to come out. We would do absolutely everything we could to avoid this scenario. I had measured the blood we had in the bucket and it was 3 liters.

Eventually, about 3 hours into the whole ordeal and once the second unit of blood had been given, the patient stabilized. Her heart rate was a more reasonable 110bpm and her blood pressure had come up a bit as well. Her respirations were normal.

In the meantime, I did the ultrasound and saw that all was well with the baby. There was no abruption of the placenta or any other reason for bleeding that I could see. I performed a vaginal exam and her cervix was closed and felt normal for 32 weeks gestation. Her vaginal bleeding was minimal but given the circumstances, we still needed to find out why she had bloody diarrhea, bloody nose and now vaginal bleeding. Hemotology is not my area of expertise and I was relying on the MD to figure that part out while I came up with a treatment plan for the patient from the obstetrical end in the last couple of hours I had before departure.

After looking over the labs and looking at the big picture, it was agreed that the patient probably had disseminated intravascular coagulation (DIC). DIC is a rare and serious condition that disrupts blood flow. It is a blood clotting disorder that can turn into uncontrollable bleeding. First, DIC creates many small blood clots that keeps blood from traveling through the body. When this happens, the blood is not able to bring oxygen and nutrients to the brain, heart and other organs. Then, having used up the proteins and platelets that make the blood clot, DIC causes uncontrollable internal and/or external bleeding. It is not exclusive to pregnancy, anyone can get DIC and although not common in pregnancy, it is a leading cause of maternal mortality.

DIC is usually diagnosed based on blood tests – PT, PTT, FDP – none of which we had but we did have her hemoglobin and hematocrit as well as her platelet count and they were all life-threateningly low. DIC was the only diagnosis that made sense. Its presence in a pregnant patient invariably means there is some other underlying illness. In the case of this patient, it was probably sepsis.

The patient develop a fever later and respiratory distress. The treatment and management for DIC depends on the cause and in low-resource settings, it differs somewhat from what would be done in a developed country where blood tests, medications and blood products were in full supply. She was given a transfusion, antibiotics and she was on oxygen. The last thing I told the MD was that he needed to have the IPD staff monitor the patient closely for contractions. They were not used to doing this since they are not usually caring for pregnant patients. I told him in all likelihood the condition of the patient would set off labor and it would be a good plan to give dexamethasone to help the baby’s lungs mature. Also, the staff needed to call maternity as soon as they saw any signs of labor. I left the project that day not knowing if she would live or die.

I spent 2 days in Juba debriefing. While there, I stayed in touch with one of the MDs to get periodic updates on the patient. She was still alive. As I had predicted, she gave birth in the middle of night the day I left. The MD was surprised. Not sure why since I told him this was going to happen but it was no longer my concern. In the days that followed, she would have a total of 6 blood transfusion before they decided they would give no more since they could not get her hemoglobin above 6. They would just provide palliative care.

After nearly a week at home, it was still difficult to let go of the last 8 hours of my assignment. I kept replaying all of the things that happened both with the hemorrhage and the DIC. Having 2 patients that I thought would die on the very last day of mission, was very traumatic. I had never had the experience of coming home from a mission and not being able to just detach. Because I felt I needed to know if the DIC patient survived or not, I kept in touch with the MD who was most closely managing her case. She kept me updated. It was through her that I learned they had put her in palliative care. Her baby was fine; small but fine.

About 10 days after leaving the project, I received a message that the DIC patient had a platelet count of over 200! She was doing much better and she would survive. Against all odds, in this low-resource setting with everything stacked against her, this woman survived. She would not be a maternal mortality statistic. The relief flooded through me. Even though it had nothing to do with me anymore, I still cared about the outcome, how could I not?

After that message, after learning this patient was going to live, I was able let go of the mission, finally. I was able sleep better and to be home and be present for myself. Although I do carry a certain amount all the time, I had never had the experience of bringing so much home with me and it was exhausting. I am relieved to be on the other side.

***For more photos from the field, you can follow me on IG @globalmidwife64***

The Cost of Caring

Compassion fatigue is real. Often referred to as, the cost of caring, compassion fatigue and it’s often accompanying companion, vicarious trauma, can take their toll even on some of the most seasoned first responders, healthcare providers and humanitarians. No one is immune.

From a personal standpoint, I have suffered the effects of compassion fatigue more times than I care to think about. It happens less frequently now because I have learned how to care for myself better while out in the field and I have learned how to use the resources and tools at my disposal. Still, most of us in the field are just one critical incident away from the clutches of compassion fatigue.

This assignment in particular has been challenging in ways I could never have anticipated. Just over a month into it, my mother became critically ill and I flew home to see her before she died. It was a crushing blow. It took everything I had just to get up in the morning. I had to think about whether going back to the project was the right move for me. I had to weigh the benefits and downsides. I needed to get out of my emotions and just look at it in a practical way. In the end, I made the decision to return, partly because I knew I would be busy and distracted and this would be good for me and partly because I had a sense of obligation and wanted to fulfill my commitment to the project, even though no one in the organization would have blamed me if I had not. I just knew staying home, as winter approached with its cold, dismal weather, would only serve to exacerbate my grief and depression. I knew I would start feeling bored and useless within 2 weeks and would regret not returning, so I decided to go back. In the end, I can say it was the right decision, at least at that time.

Within the confines of the barbed wire compound, I manage to enjoy the myriad birds that I believe have come to sing just to me. This day, I was graced with a Southern Pied Babbler.

For this particular assignment, there is the every day stress of dealing with emergencies, ever-changing circumstances in the camp – flooding, Hepatitis E outbreak, SGBV*, external violence in the area and cholera. Then there is the weather, 100°+ most days and dry (this time of year). There are the health issues that come with environments such as these, malaria, acute watery diarrhea and the ever present threat of COVID-19, for which we are at high risk just by virtue of the fact we work in a hospital! COVID also takes out national staff, leaving staffing shortages which leads to a high work burden on everyone else in the hospital.

Even though I feel my decision to return was the right one, grief has taken its toll on me during this mission. In this particular context, there is usually a maternal death every 6 months or so, basically 2 per year. However, in the last months we have had more than our share of maternal deaths – one due to COVID-19 and four due to hepatitis E – and they weigh heavy on the soul. Although there was absolutely nothing that could have been done for any of these patients other than what we did, it is difficult not to feel weighed down by the sadness of a young life lost. This just adds to the burden of grief.

The unbelievable agony of listening to someone in acute respiratory distress, struggling for each precious breath, is not something I would wish on anyone. At the end of the day, it is difficult to put these kinds of experiences out of your mind and just rest. There is always the feeling of thinking you could have done more. In truth, we usually are giving way more than is required but ego gets in the way allowing us to think we had more control over the situation than we actually did. It isn’t a healthy way to cope; and at the end of the day, there is nothing heroic about working ones self into mental and physical exhaustion.

The food is quite tasty. I just don’t want to eat it anymore!

I am sometimes asked how I deal with all I encounter in the field. Short answer is, sometimes I don’t. Sometimes I am an epic failure at dealing with compassion fatigue, burn-out and vicarious trauma and it really takes its toll. I have the added burden of Complex PTSD that gets exacerbated during these times as well. Insomnia, anxiety, fatigue, forgetfulness, hypervigilance, agitation and being quick to anger are just a few of the things that are triggered. I has taken me weeks to finish this post because it has been overwhelming just thinking about it. However, during times when I am able to manage, what helps me through the most are a few small things. The first one is, I look for something good scattered between the trauma of the day. It may be as simple as a bird I have not seen before or even one I have but it is still rare, it brings me a lot of joy. Maybe the cook made one of my favorite foods and I am so grateful I could cry. Little things are huge in an environment such as this one.

I also prepare for assignments knowing there will be hard times. I pack essential oils because the smell of lavender or rose calms me and I have a little diffuser (thanks Augustine!). I have my wind chimes and just the sound of them makes me happy. I reach out to friends back home and sometimes this will help ground me. I don’t reach out to discuss how miserable I am but rather to hear about their lives and what is happening and to just hear about regular life and other peoples problems. It is a delightful distraction. I have a very select group of people on whom I call because they know exactly how to be with me – just normal! They know if I want to talk about anything here, I will, otherwise the don’t ask beyond a cursory, “how is going?”.

Now, with the promise of home less than 2 weeks away, I am savoring every minute of time here. The sweltering heat, the food – of which I am now tired of due to its repetition, not because it isn’t good, the patients, my staff, each birth, every challenge – all of it. I am in the home stretch and I can feel it and it has given me a second wind of sorts. Still, the exhaustion comes through the cracks at times and I know when I finally leave the project, I will be leaving a job well-done; it will be a welcome relief to my mind, body and soul.

*Sexual and Gender Based Violence

***For more photos from the field, you can follow me on IG @globalmidwife64 ***

Friday: Death and Birth

I have 2 more weeks before I am home and I feel like a long distance runner nearing the end of the race and getting that final burst of energy to make it across the finish line. In these last few weeks, aside from all of my tasks here, I managed to get in a podcast interview with Blyss Young, midwife and Stuart Fischbein, OB. They have a podcast called Birthing Instincts. Amazingly, the internet cooperated and only went out once the whole time! I had a lot of fun chatting with them even though there was a slight delay and a few people have messaged me asking if I was ignoring Stuart’s questions on purpose! LOL! No, I was not. Here is a link to the episode in case you missed it: https://podcasts.apple.com/us/podcast/245-birth-stories-from-south-sudan-with-kristine-lauria/id1552816683?i=1000550543216

Today was not a busy day in terms of volume but what we did have was eventful enough to keep us on our toes. The first patient was one sent from another facility because she needed a transfusion. She was 20 weeks pregnant with her first baby and had a hemoglobin 3.1. Our goal is to get the patient to at least 6, which is a very low bar but is all we can hope for in this environment. We knew she would need at least 2 units. We tested her for malaria, HIV, syphilis – all the standard things, and everything was negative. We have no idea what is causing the anemia but she will likely need more blood as her pregnancy progresses and her blood volume expands.

After the first unit, her hemoglobin went up to 3.4, not impressive. We gave her another unit and it came up to 4.1. We are still awaiting relative that will donate more blood so she can have another transfusion in the coming days and then hopefully have some blood on hand for her in the future. She will likely not get through her pregnancy without more transfusions. Will we ever figure out the cause of her severe anemia? Not likely.

The next patient came in preterm labor at about 26 weeks. She already had given birth 3 times but those babies had all been term. We tested for malaria and UTI, the usual things that cause preterm labor here, both were negative. There was no abruption and the fetal heart rate was strong, so it wasn’t a demise.

These preterm cases are always difficult when there hasn’t been a demise because the babies are usually born alive and because there is really nothing we can do for them, they just get wrapped in a blanket and stay with the mother until they die. It is always difficult to watch.

Preterm labors are usually quite short and we were watching this mother closely. She didn’t tell anyone that she wanted to go to the latrine though, so that is how I ended up in the doorway of a latrine with a mother squatting down and holding a micro premie between her knees.

This tiny girl weighed in at 750 grams and in usual fashion, we wrapped her and kept her next to her mother for the short time she was with us.

In the bed next to the preterm patient, was a mother having her 5th and 6th babies. The first was presenting head down and the second was breech. The labor was active when she arrived so I knew she would birth within hours. Both babies sounded good when I listened. She was 38 weeks in gestation so I wasn’t anticipating any issues. This was the second time she was having twins.

When she finally shuffled back to the birth room, without much effort she pushed the first baby to the perineum and then the head was out on the next contraction. It was 3:59PM. That baby was a boy and weighed in at 2.73kg, a nice size.

I listened for the heartbeat of the second baby and the mother seemed surprised there was another baby in there. I asked the midwife why she was surprised and she said, “she thought maybe you were joking about twins”. Just a few minutes later she started to bear down again. A bag of waters came down and out and then exploded as amniotic sacs are known to do! The fluid was clear and there was a butt cheek and a foot coming down so I knew the baby was complete breech. In one push she brought the baby down and out to the shoulder blades, then the arms came simultaneously and then the head popped out and the baby fell right into my hands. It was 4:03PM.

Both births seemed fairly effortless from where I was standing and the placenta, an enormous thing as big as any placenta I have ever seen with twins, came out before we even had a chance to give her an oxytocin injection!

The second twin, also a boy, weighed in at 2.17 kg, so slightly smaller than his brother. The placenta was beautiful and looked very healthy and when we examined it, was saw it was complete and there was 1 chorion and each of the boy had their own amniotic sac.

With both babies doing well, we did our newborn things and then wrapped them up and tucked them in with their tired mother. As happy as we were for her, it was bittersweet. The juxtaposition of the mother with the premie that had just died, in the bed right next to the woman who had just given birth to not one but two babies, seemed like a cruel twist. But this is how it is in South Sudan, and places like it. There is tragedy next to joy around every corner.

***For more photos from the field, you can follow me on IG @globalmidwife64 ***

Gestational Trophoblastic Disease

Early in my midwifery career, during my apprenticeship in fact, I learned about gestational trophoblastic disease firsthand. It fascinated me from the start. Here in South Sudan, I have seen several molar pregnancies per month, every month. Each case is unique and some of them are more complicated than others. This post will be a little more clinical/technical than others and may not interest those who are not midwives but I did my best to write in terms most people can understand.

For readers unfamiliar with molar pregnancies, I will give a brief overview. Gestational trophoblastic disease (GTD) is the term given to a group of rare tumors that develop during the early stages of pregnancy. After conception, the body prepares for pregnancy by surrounding the newly fertilized egg with a layer of cells called the trophoblast. The trophoblast helps the embryo implant itself to the uterine wall. These cells also form a large part of the tissue that make up the placenta. In GTD, there are abnormal changes in the trophoblast cells that cause tumors to develop.

Most GTD tumors are benign, but some have the potential to turn malignant. GTD is usually classified into one of two categories:

Hydatidiform moles
Gestational trophoblastic neoplasia (GTN)

A hydatidiform mole is also known as a molar pregnancy. In a molar pregnancy, there is a problem with the fertilized egg, and there is an overproduction of trophoblast tissue and the excess tissue grows into abnormal masses that are usually benign but can sometimes turn cancerous. There are two types of hydatidform moles:

Partial mole: The fertilized egg contains the normal set of maternal DNA but double the number of paternal DNA. Because of this, the embryo only partially develops and does not become a viable fetus.
Complete mole: The fertilized egg has no maternal DNA and instead has two sets of paternal DNA. A fetus does not form.

There are several types of gestational trophoblastic neoplasia:

Choriocarcinoma: This cancerous tumor forms inside the uterus. Choriocarcinomas usually occur when growths from molar pregnancies turn cancerous. Rarely, choriocarcinomas form from tissue left in the uterus after a miscarriage, an abortion or the delivery of a healthy baby.
Invasive mole: Trophoblast cells form an abnormal mass that grows into the muscle layer of the uterus.
Placental-site trophoblastic tumor: This extremely rare, slow-growing tumor develops where the placenta attaches to the uterine wall. Placental-site trophoblastic tumors are often not discovered until years after a full-term pregnancy.
Epithelioid trophoblastic tumor: Extremely rare tumor and it’s progression mimics that of a placental-site trophoblastic tumor.

The only way to prevent GTD is to not become pregnant. Risk factors for GTD include, age under 20 or over 35, previous GTD and history of miscarriage. None of these risk factors can account for why we see such a high rate of molar pregnancies here in the camp in South Sudan.

Due to the cystic degeneration of the placenta (abnormal proliferation of the chorionic villi) the mole presents in the form of translucent vesicles, 1-2 cm in diameter, connected by filaments like a cluster of grapes

Here in the field, patients with molar pregnancies will often present with bleeding and then upon exam and ultrasound, the mole is discovered. Other times, when a patient comes in for a prenatal exam, no fetal heartbeat is heard and then upon ultrasound exam, a mole is discovered. Some of them can go to 20 weeks or more undiscovered in places like this because women often do not seek care until their pregnancy is more advanced or they have an issue.

The pregnancy test is always positive. Hydatidform moles are commonly associated with markedly elevated hCG levels often in excess of 100,000 mIU/mL with complete moles. Here in the field, we do not have quantative hCG so we cannot use this as part of our diagnostics and must rely on the other signs for diagnosis. Partial hydatidiform moles do not have the same presenting features as complete moles. Although the main presenting symptom is also vaginal bleeding, which occurs in about 75% of patients. Fewer than 10% of patients with partial moles have hCG levels > 100,000 mIU/mL. More than 90% of patients with partial moles have symptoms and ultrasound findings consistent with an incomplete or missed abortion, and the diagnosis is usually made only after MVA or currettage is done. I have been surprised a couple of times!

Classic image of a complete molar pregnancy

With a complete mole, ultrasound will show a heterogenous vesicular placenta filling the entire uterine cavity. The characteristics of molar pregnancies on ultrasound is called snowstorm or grapes in a snowstorm because of it’s grape-like cluster appearance. It’s unmistakable. A partial mole can be a little harder to detect and can be somewhat confusing if one is unsure what they are looking at or isn’t suspecting a mole.

It is helpful to see what a complete mole looks like when it expels on its own. In Bangladesh, we had a patient who came in at 20 weeks gestation in preterm labor with some bleeding. We did not get a heartbeat and we did not have ultrasound. We assume it was a fetal demise. On exam I could feel there were notfetal parts presenting and what felt like placenta through the cervix, which would explain the bleeding. She was not in maternity long before starting to push. Out came a complete mole totally intact. As you can see, the cyst-like features are what show up on ultrasound most often. Not all moles are this classic. Some have more placenta-like qualities to them. On manual vacuum extraction (MVA), the mole comes out in bits so it is rare to see one intact unless they expel spontaneously.

GTD is oftentimes accompanied by bleeding and this is most often what brings a patient into maternity if the mole had not been previously diagnosed on early ultrasound. I have not personally experienced much hemorrhaging but we carefully manage these patients as soon as they present with the express purpose of preventing hemorrhage.

The aftercare of a patient with GTD is very important. In about 10 to 15% of patients with a complete mole,will develop post-molar trophoblastic neoplasia (choriocarcinoma). Between 1 and 5% of patients with a partial mole will develop choriocarcinoma. In light of this, we have very specific guidelines in the field appropriate for low-resource settings such as ours. Note, they are much different in resource rich settings.

The patient is counseled on family planning and we explain it is best to avoid another pregnancy for at least a year. Two weeks after MVA, the patient is asked to return for a repeat ultrasound to make sure the uterus is empty. Even when MVA is done correctly, retention of molar debris is not uncommon. When we do not have ultrasound at our disposal, we rely on clinical signs like persistent or recurring bleeding after MVA.

Eight weeks after MVA, we perform a pregnancy test. It should be negative by that time. If it is, then we ask the patient to come back at intervals of 4 to 8 weeks for 1 year. If the test is positive or becomes positive at any time during that year, persistent trophoblastic disease or choriocarcinoma is suspected. Often in the field, there is no place to refer the patient even if we detect the hCG or she becomes symptomatic. This is very disheartening. Without very aggressive, specific treatment, choriocarcinoma is 100%. It is the fastest growing cancer there is and the patient usually dies within a year.

Most recently, a patient presented with bleeding at 16 weeks gestation and no fetal heartbeat, incomplete abortion was diagnosed. she was 35 and had 9 children. She had been referred to me because the midwife in the other project was unable to penetrate further than the inner os while attempting MVA. She suspected it may be a molar pregnancy but was not sure on ultrasound.

The patient was flown to our project and I repeated everything the first midwife had done. On ultrasound exam it did look like a hydatidaform mole to me and I attempted MVA as well, how hard could it be? Well, I experienced exactly what the first midwife described. I could not get the cannula to advance beyond the inner os of the cervix. Okay then! I presented this case to the surgeon. I believed the patient needed to go to OT because there would be no way to get the uterine contents out otherwise. We did an ultrasound together. He saw what I saw and thought it may be a fibroid. I disagreed. It should be noted, he is a general surgeon and not a gyn. I told him either way, the contents could not be evacuated through the os and I doubted whether even a D&C would be successful, which was his first suggestion to me. He did not know how to do them but wanted to learn so he suggested we try that first and I could teach him. When I explained that my working theory was that this was an invasive mole and was similar to a placenta accreta in that it had likely grown into the endometrium, he understood the issue.

We discussed how to proceed. I explained that I thought the mole was taking up the entire uterine cavity because that is how it looked on ultrasound and this is what hydatidiform moles did. So if this was the case, it would not be possible to do a laparotomy and myomectomy because I did not think the contents would come out. Due to the fact that the surgeon had never done any gyn surgeries aside from c-section, he wasn’t keen on changing course mid-surgery if the myomectomy proved fruitless. Planning on hysterectomy from the start was likely a better option.

We don’t routinely do planned hysterectomies because they are generally not lifesaving. We needed to get permission from the hospital coordinator before scheduling the surgery and then counsel the patient and get her consent as well. Since without the surgery, the patient would continue to have pain and bleeding and then potentially start to hemorrhage, I was certain the hospital coordinator would okay it and she did. I told her I could be wrong with the diagnosis but I really did not think so. Or if I was wrong, there was still something large in her uterus that needed to come out and likely could not come any other way. The patient also agreed. She said 9 children were enough for her and would do the surgery, so we schedule for the next morning.

There were 3 of us including the surgeon. I was there primarily to photograph but ended up assisting as well as soon as the adhesions became apparent

The surgery took about 3 hours. There were bladder and bowel adhesions but everything went well and the patient did not lose much blood, something we are always concerned about because it is difficult to get family donors and we don’t have a blood bank per se, usually just a few units left over from someone who ended not needing blood after it had been donated. The surgeon removed a very unhealthy looking uterus. Even from the outside, you could tell it was diseased. Once dissected, it was obvious the trophoblasts had completely invaded the myometrium. There would have been no possible way to get this out of her uterus because it had completely taken it over. I was quite relieved. And curiously enough, it looked exactly as I imagined it would.

As I mentioned in the beginning of this blog post, my first encounter with choriocarcinoma was during my apprenticeship. It was a very profound experience and had a huge impact on me personally and professionally. My client died but she had refused treatment. I wrote the whole story several years ago and it can be accessed here: http://www.naturaltransitions.org/wp-content/uploads/2011/10/NTM-Sampler-April-24-20121.pdf

Here is South Sudan, the patient recovered well and had a very uncomplicated post-op. She was flown home a week later. She will continue to be followed by the other project where she had come from. She is aware of what we found and what it could possibly mean, although without further pathology, it is difficult to know anything for sure. I am not very hopeful from what I saw that her prognosis will be very good, however, I have seen some of the most miraculous things happen over the years and I would never pretend to know someone’s fate nor am I an expert on this subject. I do hope the odds are in her favor.

***For more photos from the field, you can follow me on IG @globalmidwife64 ***

Hand presentation…or is it?

I ended 2021 on a high note in terms of birth experiences. This story is awesome and hilarious all at once. Just when I think I won’t run into a scenario I haven’t already experienced, I do!

The COVID situation here has exploded just like in the rest of the world with the omicron variant rampantly taking over and taking down staff members left and right, expat and national staff alike. How long we will be able to run a hospital with an ever shrinking staff, only time will tell. As of now, even the surgeon and anesthesiologist are isolated. Expat midwife, so far, so good.

COVID has also not bypassed the maternity ward and 3 patients were identified on the same day and sent to the COVID isolation unit. One was preterm, 32 weeks with premature rupture of membranes and no labor, one was 37 weeks with severe anemia that had been transfused twice and one was post-op (placenta previa) and although she had been discharged, her baby was preterm so she was still inpatient due to his status.

A round tukul in COVID isolation was transformed into a maternity area where patients could birth and stay postpartum. In a matter of hours, the team responsible for completing such tasks had gotten the floor completely covered with tarp (for easy clean-up of biohazard), had a sink with cold running water installed, lighting and 2 beds. This was just in time because the patient who had the PPROM had started labor. I knew she would not labor long so I was just biding my time. I also had to go into OT to do a procedure with a patient and I knew by the time I got out, the tukul would be ready and so would the patient. Sure enough, just in time everything had been set up and when I went back to COVID isolation, I found my patient quietly laboring in the tukul. All I needed to do what set up my portion of the supplies and we were good to go.

Once I set everything up, there was not much else to do but sit and wait, and sweat. It is about 100° any given day. In full PPE, it feels like 120°. I could not disrobe and wait elsewhere because there was no one else to monitor the patient and once I disrobed, I had to throw everything away. The waste couldn’t be justified. I was completely drenched in sweat within 15 minutes.

I sat quietly next to the mother. It was her 5th birth so I did not check her cervix or do anything unnecessary. She had already had ruptured membranes for over 24 hours and was getting antibiotics for that. Even without language skills, I knew I would be able to communicate with her and certainly I would know when her labor was progressing. I did listen to the baby a few times. She had time to get in 2 rounds of dexamethasone which would help the baby’s lung maturity since it was only about 32 weeks. I was expecting the baby to be small but fine.

I knew from previously palpating her abdomen that the baby had been in a breech position. I could see the head was still at the fundus and I knew she would not push long once she started pushing because the baby was small, it wasn’t her first and it was breech. Again, I wasn’t expecting any issues.

I usually encourage breech mothers to be upright for birth as it is optimal and the baby can maneuver the pelvis more easily. But this mother was sick with COVID and in no condition to be anything but horizontal. Thankfully she was not on oxygen, she was just feeling very unwell. The baby was small and likely would not require any maneuvers and if it did, I could do them supine.

Some time passed and I could tell the baby was moving down by the sounds the mother was making. I said nothing and did nothing. She was doing what she needed to do and once she started to open her legs and bear down slightly, I knew it was getting close. It was not long before I could see something small emerging – toes…no, a hand! My reaction internally was one of, how could this be? I KNEW the baby was breech. When did it flip? It didn’t look transverse. A cascade of things went through my mind and at the same time, I was saying to the mother, “no, no, no, just let me reposition this!”. Of course that did not go over well because she couldn’t understand me AND she had an overwhelming urge to push! So just as quickly as I replaced the hand and tried to reposition and figure out what was going on, she was bearing down against me and the hand emerged and…a shoulder? head? what?

My brain was rapidly trying to catch up with what I was seeing and feeling. The cognitive dissonance this created was overwhelming for just a few seconds and then everything fell into place. After a big push the entire hand came out again a little further up the arm along with another presenting part which I then saw had a little dab of meconium. It was a butt. As she emerged I realized what was going on. She had her arm behind her back, palm up, over one butt cheek, something I had never seen in all my years attending births – a compound presentation of a complete breech with a hand! The baby continued to slip out easily right up to the neck and the little head popped out and I placed her on her mother. She cried immediately. WOW!

I sat there stunned and elated. I could believe what I had just witnessed. I would never even have thought to conjure up this combination in my wildest dreams. All was well. The placenta came out, I got everyone cleaned up, did all the documentation and weighed the baby – 1.76kg, not too bad!

I gratefully took off my PPE, left the isolation unit and headed for maternity. There I was met by a mother who had just arrived pushing. Within minutes a little boy was born, face first into the world. These would be the last births I attended in 2021.

Hepatitis E and Maternal Mortality

Hepatitis what? E? “I’ve never even heard of that!” I heard this statement over and over again when speaking to friends and colleagues back home. It isn’t surprising, Hep E is not at all common in the developed world. For future reference, and to dazzle your friends at any cocktail party over the holidays, there is hepatitis A,B,C,D & E (so far). Hepatitis D requires a hepatitis B virus for its replication – go figure!

According to the World Health Organization (WHO), there are 20 million cases of HEV worldwide and of those, about 3.3 million are symptomatic. “HEV infection is found worldwide and is common in low- and middle-income countries with limited access to essential water, sanitation, hygiene and health services. In these areas, the disease occurs both as outbreaks and as sporadic cases. The outbreaks usually follow periods of fecal contamination of drinking water supplies and may affect several hundred to several thousand persons. Some of these outbreaks have occurred in areas of conflict and humanitarian emergencies such as war zones and camps for refugees or internally displaced populations, where sanitation and safe water supply pose special challenges.” (WHO) So you can imagine, here in a refugee camp, we are ripe for a HEV outbreak and that is just what we have now.

Last Sunday, a woman brought her sister in to the hospital ED and that department brought her to us because she was pregnant. They think anyone who is pregnant should be seen in maternity regardless of their chief complaint. “Um no, this patient has an abscess on her foot, this is not pregnancy related”, I have been known to say. Then dejected, the nurse takes the patient back to the ED. But this particular patient was a mystery. We could see she was pregnant but she was agitated and uncooperative and we were unable to even examine her because she would scream and finally threw herself on the floor and rolled around screaming anytime anyone came near her. Her sister brought her in because she had been acting strangely and had periodic bouts of screaming for the last couple of days.

I knew this patient did not belong in maternity not only because her illness was not pregnancy related but also because we were full and she was frightening and disrupting all of the other patients. We don’t have a psychiatric unit, although we do have a mental health department but they do not work weekends. I needed to get her to calm down so we could take her to another place where she could be examined so we could try to help her. I called the pharmacy for haloperidol but it was ruptured. So the next best thing to try that I had on hand was diazepam. It took 4 people to hold her down so we could give her the injection. It did help slightly and she was calmer but still not responsive when spoken to.

I called the MD on call to help me deal with the patient and transfer care. He came and we made the decision to take her to TB isolation. There she could be in a room alone where she was not a threat or disruption to others and she could be examined and treated. We wanted to know if the pregnancy was viable, among other things.

We asked the sister about her history. She was 20. This was her second pregnancy, the first was term twins and both were still alive. She had had no recent trauma, injury, accident, illness or any other incident that might have triggered the symptoms. She continued to be agitated after being brought to isolation so she was given another injection of diazepam so that I could do a quick ultrasound to check the baby. There was a heartbeat and it looked to be about 27 weeks.

In the meantime, we also got blood drawn. The MD suspected HEV because once we could examine her, we saw her eyes were jaundiced. Of course we tested for all hepatitis and malaria. Everything came back normal with the exception of the ALT which was elevated – 1376 (should be no more than 55), and Hep B & E, which were positive. So we had our diagnosis which explained her symptoms – hepatitis E encephalopathy. She would not recover. Her brain was swelling and her liver was failing and it was a matter of time before her body completely shut down.

The family gathered and were informed of her condition. She was to be given palliative care which included morphine. A DNR was added to her chart at the family’s request. I check the fetal heart rate every 6 hours or so. We did not know if the baby would be expelled or not. The last case we had of a pregnant woman with HEV, the baby did expell. It was about the same gestation. We had to be prepared for the same thing to happen. The heart rate was stable during the first 24 hours but as the mother started to deteriorate, there was fetal distress and the heart rate was in the 190’s. I knew the next time I went to listen, it would no longer be there.

The decision was made not to intervene with the pregnancy, either by induction or c-section. It would not change the prognosis for the mother and the baby may or may not be able to survive at the current estimated gestation.

Pregnant women with hepatitis E, particularly those in the second or third trimester, are at increased risk of acute liver failure, fetal loss and mortality. Up to 20–25% of pregnant women can die if they get hepatitis E in the second or third trimester. We have seen this to be true here in our project. We have had 4 pregnant patients in the last year very similar to this, although not presenting with symptoms of agitation and disorientation like this one. All of them died within a few days of presenting at the hospital. Some studies have shown a three times higher relative risk for fulminant hepatic failure and a six times higher risk for mortality for pregnant patients.

Typical signs and symptoms of hepatitis include:

an initial phase of mild fever, reduced appetite (anorexia), nausea and vomiting lasting for a few days;
abdominal pain, itching , skin rash, or joint pain;
jaundice (yellow color of the skin), dark urine and pale stools;
a slightly enlarged, tender liver (hepatomegaly).

As it turned out, I did not have to check the fetal heart rate again, there was no next time . She died in the night and her baby died along with her. Her family was there. Her suffering was thankfully short. Still, it was incredibly sad. She left behind a family, including a husband and 2 year old twins. The cause of death was hepatic encephalopathy with acute liver failure.

When I am asked what is the usual cause of death for women during the childbearing year when I am on assignment, it is usually hemorrhage or infection. But there are other things, incidental to pregnancy that sometimes we can do nothing about. Even if this woman had sought care sooner, in the early phase of the illness, it is likely the outcome would have been the same. It is frustrating and sad. I allow myself those feelings for a few minutes and then I let them go and move on to the next patient. There is always someone else waiting to be helped and this is where I put my energy and focus. It is the only way I survive.

***For more photos from the field, you can follow me on IG @globalmidwife64 ***

Twins, twins, twins!

Let me start by saying, South Sudanese women are strong! I have attended 13 sets of twins since my arrival and 3 sets in the last week! The last 2 sets were quite something. I may start buying lottery tickets!

The first mother was a grand multip, 35 years old, G8 and she was term. She walked in to the birth room and started pushing. Out came a beautiful baby perfectly encased in the caul. It was a little girl. Not 2 minutes later, her sister decided to join us. First a big balloon of water came out and then she slipped her head out right into the bubble and then the rest of her was born. Both babies completely born in the caul. Both girls weighed 2.6kg.

One of the placentas had a cord with a side insertion.

The placentas soon followed and there was minimal blood loss. I am always prepared for more blood loss with twins and with a grand multip, but both, I prepare for hemorrhage. So I was thrilled she did not bleed. But after the second baby was born, a look of worry came over the mother. Then she pointed to her belly. I realized she wanted to know if there was another one in there! I assured her there were only 2 by smiling and holding up my fingers. She smiled broadly. Once the placentas were out, I said, “calas” (finished), she got up, walked out the door to the amazement of the other women on the ward who had just seen her walk in less than 20 minutes ago. Now she came out with 2 babies trailing behind her!

The next twin birth was basically a repeat of the first! 36 year old, G10 who not only was term but it was her due date! She walked into the birth room and started pushing. It wasn’t long for a bag of water to appear and then a little head inside of it and out slipped a little girl. I had to puncture the sac because it was still intact even after she came out. About 7 minutes later, another sac appeared and this one I could see little feet and a butt as it emerged. The whole baby, head and all came out encased in the sac all curled up, a perfect little complete breech. If you don’t want any issues with a breech, don’t break the bag of waters, they come out without issue because there is nothing to get hung up on the pelvic bone since they are still all curled up with head tucked.

Both babies were girls. They weighed 2.7 and 2.6 kg. The placentas soon followed and blood loss was less than 400 mls. She got up and walked to the shower. About 20 minutes from start to finish. Both girls were healthy and had very strong opinions about being out in the world as was evidenced by their very loud voices. Their mother looked dazed and overwhelmed.

The very first set last week was truly special. The mother was a little younger, 28 years, and was only G3. But she still walked in and barely made it to the birth room before the first baby was born. She was vertex. It was about 3 minutes and the second baby came, complete breech. She was a carbon copy of the first baby, truly. Both babies weighed 2.1kg. These were not born in the caul. The bag of water broke just prior to birth. The placenta came about 10 minutes later and it was then that I saw what they were – monochorionic-monamniotic.

Mono-mono twins are estimated to occur about 1 in 35,000 to 1 in 60,000. They often come with a myriad of complications and when diagnosed early in pregnancy, are closely monitored.

Here in South Sudan, we take what we get. Sometimes we are pleasantly surprised. Both girls are healthy and the pregnancy was term. Sometimes it is nice not to know what you are dealing with before hand.

There are a lot of superstitions in Africa about twins. Here in South Sudan in previous generations, people held the belief that twins were not human. I have no idea of the origin of that belief and no one can explain it to me. They generally held a negative connotation. Some people believed that the mother or father of the babies would die if twins were born. Still others just considered them bad luck. It seems like in recent years the superstition surrounding twins has turned around and people now welcome twins and they are a reason for joy and celebration. I know in our maternity, everyone loves seeing 2 babies come out of the birth room. Every set of twins we have had since I arrived has been full term. They have presented in every combination of presentation there is including vertex/transverse. The transverse after coming twin did not want to go either breech or head down and any any attempt to turn her was thwarted. Since I didn’t want to lose her, I decided to do a breech extraction. It worked beautifully and the baby came right down and out.

I have learned after attending a few hundred sets of twins and a handful of triplets, that things most often`go well with multiples. Most of the time they go to term. Most of the time birth goes well, particularly when the process is left undisturbed. It speaks volumes that in developing countries, with the best healthcare in the world, twins are often preterm, often c-section or high intervention vaginal births. And by comparison, women in some of the poorest countries in the world, living in conditions that can only be considered deplorable, with sub-par nutrition and poor sanitation, tend to have much better outcomes when birthing with a skilled provider. The difference, I think, lies in the approach – the medical model versus the midwifery model. One looks constantly for all the things that can go wrong and that is the sole focus. While the other comes from the perspective that birth is a natural process and things will most likely go well, all the while still being vigilant for anything out of the norm but not focusing on that aspect.

The same is true from the birthers perspective. People in developed countries tend to focus on the “what ifs”, while women in the developing world are often just struggling to survive day to day, particularly in refugee camps, disaster areas and war zones. They carry their babies and give little thought to the pregnancy itself or the process of birth. They just do it.

***For more photos from the field, you can follow me on IG @globalmidwife64 ***

Breech Story

I arrived in maternity at 2:12. I left by 2:47.

Middle of the night breech, my favorite and this one was particularly beautiful. First time mom, 18 years old, came in complete and the staff called me. When I arrived, I had to bypass a big puddle of amniotic fluid and fresh meconium – the telltale sign of a breech about to be born. The mother was already on the table. I prefer upright physiological breech but the staff is so accustomed to putting everyone on the table to examine them, they don’t think twice. I could see the baby had already descended and the mother looked like she really didn’t want to go anywhere, so I just kept her there. I believe supine breech to be more challenging in general (not always) because of the pressure on the sacrum and how the baby needs to maneuver through the pelvis. It often calls for more intervention than an upright breech and because I am here to teach staff, it provides the opportunity to show them maneuvers I would not be able to otherwise. It is also good practice for me. Nevertheless, I made sure the table back was up high so she was almost in a squatting position.

The mother pushed beautifully. If I had not known she was a primip I would not have guessed by her demeanor. A foot and a butt cheek emerged at the same time with one push. And then on the next push a foot and a testicle and then the next butt cheek. At this point it looked like the baby was in a crouching position, so feet and buttocks out to the hips, all facing transverse like the majority of complete breeches. When I see a complete like this that doesn’t bring its legs down right away, I know the head will come easily because the diameter of all these things coming through the pelvis is quite wide. This told me everything I needed to know about how things would go.

On the next push, the baby then started to emerge, first to the umbilicus and then it spiraled beautifully into an anterior position. And then, as it came out past the umbilicus it continued to rotate past anterior just a bit and released one shoulder and then the arm and then it spiraled back to anterior and again, just a little past to bring the other shoulder and arm down. It was like watching a ballet. It was all done as though it were in slow motion and it was just so graceful. I was in awe. After all these years, birth never fails to impress and amaze me.

The baby was born to the head and I could easily see the nape of the neck. I asked her to give a gentle push and the baby came right out into my hands. I never touched it until then.
The baby weighed 3.1kg. The perineum was intact. It was 1 minute and 30 seconds from bitrochanteric diameter to birth. The Apgar was 9/10.

For me, this marked my 500th breech birth. I have attended 18 breeches here since my arrival. Not all have been term but the ones that have been all had very good outcomes. All but 3 have been physiological breech, either hands and knees, squatting, kneeling or standing – always the mothers choice. Of those18, I have had to do only a few maneuvers, including, Louwen, Løvset, modified Prague, shoulder press and Ritgen. Also one breech extraction for a second twin that was transverse and would not rotate to either breech or vertex, and I used Burns-Marshall with that one as well.

When the mother is upright, I always prefer Ritgen to release the head if should press does not work. It is far less invasive than Mauriceau-Smellie-Veit (MSV), which I used frequently in the past and still do with supine breech because Ritgen is close to impossible when the mother is on her back. I have yet to have Ritgen not work for an upright breech. I have also used it a few times with shoulder dystocia.

If you want to learn more about the different maneuvers mentioned here, the very best resource on all things breech is Breech Without Borders. There you can find a wealth of videos, handouts, studies, lectures, as well as in depth courses for care providers, parents and doulas. Breech Without Borders have made it their mission to reteach breech and the impact has reached around the globe. https://www.breechwithoutborders.org/maneuvers/

***For more photos from the field, you can follow me on IG @globalmidwife64 ***

Death of a Matriarch

My mother died. The loss is tremendous. I saw it coming and I didn’t. I was prepared for it and I wasn’t. How does one prepare for losing the person that gave them life? It is a lot like giving birth, it is almost impossible to describe the pain, but unlike birth, you don’t forget this pain, not ever.

Massive widespread flooding in South Sudan made it difficult to reach the airstrip.

Getting me out of a refugee camp in the-middle-of-nowhere, South Sudan was an epic feat. It took 5 flights to get me to my mother’s bedside. My relief was immense as I watched her lie there asleep in her hospital bed. Michigan was bitter cold compared to the 104° from which I came. I had all the wrong clothes but I didn’t care, I was just so glad to finally be there.

I bought a house just over a year ago within an hour drive of my mom. Acutely aware time with her was dwindling, although she was in good health, now in her 80’s, I knew she wouldn’t be here forever. Still, I hated the thought. Death was not a taboo subject with my mom and we talked a lot about it over the years and particularly in the last year. At one point I told her she wasn’t allowed to predecease me because I didn’t want to live without her. She just huffed. I didn’t really want to die before her because I didn’t want her to have to deal with the loss of yet another child but she also knew the work I do takes me to some dicey places and it wasn’t out of the question something could happen to me. I told her if it did, not to be sad for me because I was living the life I have always wanted and doing what I loved. We had a lot of conversations like these over the last year.

When I returned from Bangladesh last November, I was to go on another assignment to Mozambique within 6 weeks. Because of the pandemic, visas were delayed and I ended up not leaving until March. In retrospect, this was a blessing in disguise. I was to spend Thanksgiving, Christmas, New Years and her birthday with my mom. We spent a lot of time together just the two of us at her house and mine. We did puzzles and watched too many true crime shows – she loved her “murder channels”, as she called them. We listened to Queen because she loved Freddie! We worked on tracing our ancestry, we reminisced, we pulled a few minor capers (my mom loved a good caper!), we got on each others nerves and we laughed – a LOT. My mother was hilarious.

I brought her flowers every week when I went to visit. It was a ritual I started after bringing them once and realizing how much joy they brought her. So I just started bringing flowers whenever I visited. She was rarely without fresh flowers. And when she came to my house, I made sure there were flowers there.

My mom did not want to be in a hospital or have any extraordinary measures taken at the end of her life – this I have known for years. We talked about it openly and matter of fact. Anyone that knew her knew this about her. She lived on her own terms and that is how she wanted to die. So the first order of business after getting her out of the acute crisis was to get her home.

Because I am no stranger to end of life experiences, I could tell from her symptoms that once we got her home, she only had a few days left with us. Also, she would not be one to linger, it wasn’t her style. One of the rare times I was actually able to be alone with her, I sat at her beside, we talked of lots of things, and secrets only we shared. We said what needed to be said. I told her how much I would miss her.

I was rather unnerved by my mother’s reaction to her current circumstance – kind of surprised – like she had of course expected one day to be in this place but not quite so soon. It made my heart hurt to see her in this turmoil, a place I suppose we all reach if we get the gift of confronting our own mortality at the end. Still, it was disquieting to watch my mother navigate these emotions but in the end, she departed this life just as she had lived it, with tenacity, humor, love, grace, and on her own terms.

The night before she was discharged home into hospice, my little niece and nephew snuck into the hospital via a side entrance, bypassing the COVID gestapo at the main entrance who only allow one person at a time to visit. Not only were my niece and nephew there, but my mom’s beloved Pomeranian, Echo was snuck in inside a reusable shopping bag – one last caper! It was worth the risk of getting in trouble just to see my mom’s reaction when she saw her dog.

I am a caregiver by nature. It is who I am and it is also what I do. But one thing I was very clear about in my own mind was that I did not want to be my mother’s end-of-life caregiver. I did not want to think about medications or dosages, vital signs or what the hospice nurse had to say. None of it interested me in the least. I just wanted to be the daughter that was losing her mother. My job is taking care of people and I didn’t want my mom to be another job for me. I am no stranger to death. I deal with it on an almost daily basis in my work and I have been at the bedside of people I loved as they took their last breath. I don’t fear death at all – not my own mortality or that of anyone else. I simply didn’t want my mother to leave. I was dragged against my will, kicking and screaming into this loss. I wanted nothing to do with it. My mother was the person I had known the longest in my life and it was as if my body, on a cellular level remembered when we were one. It remembered when she was my world and I was newly born, tiny and helpless and all I wanted, like all newborns, was my mother because that is the way nature made it. I had my mother all to myself for 16 months before a sibling would come, so during that time, I was her world, too.

My loss was so profound, I didn’t want to talk to anyone, see anyone, hear platitudes or get condolences. I just wanted to be alone. At home, I slept for 18 hours, then 12 and 14 hours respectively the first days. I have fought depression on and off throughout my life, but this was nothing like that; this was a whole new level. I couldn’t bear to be on social media because I was afraid I would accidentally see her obituary and then that would mean she was really gone, so I deactivated my accounts. I still have not read her obituary.

I would like to say that I have good days and bad days, but I don’t. All of them are bad. I feel this loss like a huge rock crushing my chest most days. It is physically painful. This must be what a broken heart feels like. I remember telling my neighbor before I departed back to South Sudan, that I didn’t know how anyone lived through the loss of their mother because it was close to unbearable. But there were people walking around all over the planet who have lost their mothers and obviously they survived, which is quite literally the only way I knew I probably would as well.

Just prior to my departure back to the field, I reached out to a couple of my mother’s close friends because I knew they were also hurting. I knew there would be no platitudes, just sadness and grief. Her friend and neighbor that lived on the bay with her, sent me a beautiful photo she took of the sunset the day my mom died. It seemed an appropriate tribute from nature and the place she loved so well.

Now, more than a month out, I would like to say things have gotten better but they haven’t really. My sweet friend, Gabriella said, “grief is an interesting thing, you start to build a relationship with it”. I am finding that to be true. It is like the relationship a kidnapping victim has with their captor – you start to identify with it and there is point when Stockholm Syndrome sets in and the grief is just a part of you, it has taken root and you give in and go along with it and are forever changed.

I remember being with my mom when her mother died. I remembered her navigating that grief. I remember how she almost instantly turned into a helpless young girl right before my eyes, when my grandmother died. I know she missed her mother until the end of her life. I also know she survived and went on to thrive. So even as grief holds me hostage, my mother has given me a glimmer of hope to hold on to, her final gift to me.

The tenacity of love

I woke up just before 5am the last day of November and went to make myself some coffee and watch the sun come up over the refugee camp here in South Sudan. As luck would have it, I had just finished making my coffee when my radio went off. The midwife on night duty said he needed me. So my coffee and I went down to see what was up.

Most of my stories start with, “I walked into the birth room and there was a patient on the table…”, this story is no different. I greeted the midwife and he proceeded to tell me that this 18 year old was about 23 weeks pregnant, she had malaria and a UTI but also had been bleeding and I could see a lot of clots that had already come out. I asked if her cervix was open and the midwife said it was not.

This patient had been pregnant once before but it had ended in miscarriage at about 2 months. After doing an ultrasound and determining there was healthy baby but a low lying placenta, I figured the bleeding must be from the placenta. I observed that the patient was having contractions. I told the midwife I thought she was clearly in labor, he didn’t think so. Not too much later I decided to check her cervix because she was having increasingly more contractions and making more noise. Preterm labor is usually not long and at 23 weeks, the cervix doesn’t even need to completely dilate.

When I checked her, she was 6cm with the amniotic sac intact. I listened and heard the baby’s heartbeat, strong and steady. She was not in preterm labor due to anything being wrong with the baby. This was disheartening because it is always easier when there has been a demise rather than another cause for the pregnancy loss – in this case, malaria and UTI. I had seen a few 22 and 23 week babies in Afghanistan come out still alive and proceed to live for an hour or so. It is such a helpless feeling to not be able to do anything for them. I dreaded having to see this again.

We have mid-term losses all the time here and usually the baby has died and that is what precipitates labor. In these cases, the baby is not taken to the morgue like a term stillbirth would be, but rather placed in the bucket with the placenta and disposed of with other biohazard. That is always hard for me but that is how it is done.

Morning shift change happened and a new set of staff came in. I was still with the patient in the birth room. I wanted to stay with her because of the bleeding and needed to be there in case of a hemorrhage. I knew the labor would not take long. I checked to see if she had any cervical change and felt a bulging water bag and broke it so we could just have this baby. The mother was ready to be done. Right after, a little, tiny red foot presented and then another and then the little body slipped down and out into my hands. What was interesting was that as small as she was, she could have come out any way quite easily. But the baby still maneuvered the pelvis the exact same way one would see with a term breech baby. This tiny little thing began to cry, a fairly loud cry considering her size. Her eyes were still fused but she had a voice. I gave her to her mother who was very happy to receive her. We had explained to her in advance that her baby could not survive at this gestation, so she knew this and understood

She lie on the birth table after the placenta was out. I told the staff she could stay there as long as she wanted with her baby until she was gone. I asked the staff to explained to the mother that we didn’t know how long the baby would survive. I stayed in maternity another 30 minutes before going back to shower and get ready for the day. The baby was still alive.

By the time I got back to the unit, almost an hour later, the mother was out of the birth room and in a bed. And there, nestled in her arms, was her tiny little girl, still alive, still moving around, still determined to get the most out of her time with us.

Hours went by, the baby lived on. At one point when I went to check on her, her mother was feeding her colostrum. Her nipple was far too large for the tiny mouth but the baby’s mouth was open and the mother was expressing drops of colostrum into her mouth. It was so touching to watch this young mother nurture this tiny little thing. I marveled at her and talked to her just as I did the other newborns in the ward. It made her mother smile.

I made sure to instruct the staff to watch for signs of the baby’s passing. The mother could go home when she wanted after the baby had died, she was already discharged. Then I told them, under no circumstances is this baby to go into the placenta bucket! They heartily agreed with me. I told them, this baby is alive and this mother has cared for her and she will go to the morgue when it is time. And I told them if they had an issue with it, they could radio me and I would come down and prepare the baby and take her to the morgue myself.

Late in the afternoon when I went to check in on the unit, the baby was still alive but now she was taking breaths far less frequently. It wouldn’t be long. I left to have dinner. When I came in later that evening to check in with the night shift, the bed was empty and I knew that little soul had finally left us.

I walked into the birth room and on the neonatal table lie a small pile of flowered cloth. In the cloth I knew was the baby. I kept her in the cloth because the family had left her with us like that so I figured they wanted her that way. I took out the white paper we use for sterilization of instruments and wrapped her up and taped it down and wrote the date and mothers name on the outside. I took the tiny bundle – barely 2 pounds – and walked to the morgue.

On my way back to maternity, I thought of the tenacity of this tiny soul, how much she wanted to be here, how, against all odds, with no oxygen supplementation, no medical care of any kind, in the middle of a refugee camp in South Sudan, she survived for almost 10 hours purely on her mothers love.

***For more photos from the field, you can follow me on IG @globalmidwife64 ***

24 hours in the life of an expat midwife in South Sudan

I wanted to chronicle a 24 hour period of time in my life and work here. I chose midnight starting on Thanksgiving Day. I am always on call but I don’t get too many calls at night usually because the staff can manage most things but they are required to call me for others. I have a radio that comes everywhere with me, including the shower. At night it is next to my head so I am sure not to sleep through maternity calling me.

At about 2:00am, I was called and the midwife said it was an emergency. I ran down and found a woman on the delivery table and blood all around. It was a placenta previa that had started to bleed. The baby was about 34 weeks gestation. We did all the preparation for a C-section, which included putting in 2 IV cannulas, a Foley catheter, sending a type and cross match to the lab along with a request for a hemoglobin level and of course, calling the surgical team. We also sent family members of the patient down to the lab to donate blood. We don’t have a large blood bank here and family of anyone needing blood always need to present at the lab to see if they qualify. The baby was born and sent to the NICU and the mother received a much needed transfusion – her hemoglobin was 4.3. At this writing, the mother is doing well will discharge tomorrow. The baby was very sick and lived for 4 days and then died.

I went back to bed around 3:30am. I received an emergency radio call around 5:00am and I ran back down to maternity. There was a mother that had just birthed and the baby was not breathing and a midwife was resuscitating him with no luck. So I started to do the Ambu bag and we stimulated him and eventually he came around slowly. The heart rate had been fine before birth and the pushing phase had not been long so we are not sure why he was so slow to start.

In the morning, a 17-year-old primip we had induced the day before was finally in active labor. She had been referred to us because of suspected pre-eclampsia and when we did an ultrasound we saw the baby had died. We induced because her blood pressure was high and she had swelling and protein and the baby needed to come out. The staff doesn’t like attending IUFD births, who would? I don’t mind because it is all part and parcel of being a midwife and you have to take the good with the bad. So once she was pushing, I took her into the birth room and helped her as she push out her stillborn baby. He hadn’t been dead much more that 24 hours. There was absolutely zero amniotic fluid, just some meconium, so I could be fairly certain the cause of death was due to cord compression from having no fluid. The birth went smoothly and the mother was back on the ward to recover.

Just prior to noon, I got a heads-up from another project that a patient was being flown in if I would accept her at our facility. It was a G4P3 term, with polyhydramnios and suspected hydrocephalus of the baby who had been in labor for 3 days. Of course I green lighted it. I headed to the airstrip, a 10 minute drive away, and waited while the plane arrived. The flight had made the patient have more contractions and the pilots were very nervous and glad to hand her over because they said they, “didn’t know what to do”. I told them that was okay, I couldn’t fly a plane!

We got the patient to the maternity and examined her, she was 8cm dilated. The ultrasound revealed a term fetus with a very large head and obvious accumulating fluid. The mother told me how tired she was and how she thought the baby was just not going to come out. I listened to her. I called the surgeon and it just happened that a patient who was due to get a foot amputated had just been bumped due to other health issues putting him at risk with anesthesia. They could take my patient to OT straightaway. I saw the relief of the mother as the surgeon explained what he would do.

I went with the patient into surgery to receive the baby. I wasn’t sure what condition he would be in although he was clearly strong because he had survived the long, obstructed labor. The surgery went smoothly and the surgeon worked hard to get that very large head out of the normal size incision. Once out, they clamped and cut the cord and handed him over to me. I took him to the table under the warming lights – he was a super heavy boy, the majority of the weight being the head. I stimulated him a bit and his heart rate came to normal and I gave him a few puffs with the Ambu bag and he started moving all of his limbs and was breathing on his own. I wrapped him in the surgical towel and then brought him across to the maternity. I weighed him, he was 4.2kg. His head was massive and there was molding off to the side, so it gave his head a more lopsided appearance. I wrapped him in the cloth his aunt had waiting. I did no further exam, no cord care, no vitamin K, no eye ointment, I just wrapped him up to keep him warm and handed him to his aunt. I had the staff explain to her that he should remain wrapped because he was so cold. He hadn’t cried this whole time and I doubted that he could. There was so much pressure on his brain from the fluid, I think much of it couldn’t function properly. Clearly his brain stem was fine because all things involuntary, like breathing, were working. I wasn’t sure how long he would live but it wouldn’t be days.

Not too much later, his mother came out of OT and was put in our recovery bed. I set her baby next to her. She looked at him and cuddled him. We had told her beforehand what she might expect. She understood. I instructed the whole staff that the baby should not be unwrapped. People here are very curious and there is literally NO privacy on the ward and other patients knew something was up with the baby, so I wanted him kept wrapped so he could just be a baby and not a zoo exhibit; he and his mother deserved that much. If he stopped breathing there was a DNR, we were doing only palliative care for him. He was in no pain or distress. I did not want staff rushing him over to the NICU if he stopped breathing, there was no point. They all understood.

That evening, we had pizza for dinner, and I thought of how everyone back home would be celebrating Thanksgiving Day and eating copious amounts of delicious food. I wasn’t missing it but I was missing my mother. I spent last Thanksgiving Day with her – the first one in decades. If the pandemic had a positive side, it was that I got to spend a lot of time with my mom, which included every holiday and her birthday and mine! It was an unexpected silver lining and those memories carry me through the hard times.

Later I would be called in when a 16-year-old primip came in in labor. They wanted me to do an ultrasound because they couldn’t find a heartbeat with the doppler. The ultrasound revealed the baby had died. Our second IUFD of the day, almost identical to the first one. She was well advanced in labor and I sat with her as she pushed her baby out, slack and still.

When I left the ward that evening, the little hydrocephalic baby was nestled in next to his mother where he would be for the rest of his life. Some time that night, he slipped away quietly. The next morning when I came in, he was no longer there and I knew.

As my 24 hours came to a close, I was roused near midnight from a deep sleep by the radio calling me into maternity. As I arrived, I followed a trail of blood from the waiting area into the ward and through the door to the birth room. One of the midwives was there with a women who had been assaulted by her husband. She had a laceration next to her cervix and that was where all the blood was coming from. The midwife had the bleeding under control and basically just wanted my support in doing the interview for SGBV (sexual and gender based violence), which is quite lengthy. Medically she was now stable and we put her inpatient so she could rest. I told the midwife we would wait and do the interview first thing in the morning when the SGVB midwife specialist was in. The fact that there is a midwife specifically dedicated to SGBV in this project, speaks volumes as to just how commonplace SGBV is here.

Aside from all the highlights here, there were the other things I do in the normal course of the day, like ward rounds with the midwives, making sure things run smoothly and we have what we need to keep the maternity going. There are 10 beds and all were full and we had to find an overflow place for patients and then decide who would go to that overflow. We are discharging patients a little sooner that we might normally because of lack of space. It is my job to help figure out all the little work-arounds so we can still have space for any new patients that may suddenly appear.

At some point that night I did make it back to bed as Thanksgiving Day came to a close. I was truly thankful for how blessed I am in my life, so much so that I am able to come to places like this and help others. It is truly meaningful and rewarding work for me and I feel fortunate to have all of the experiences I do because they help me grow.

That night, I slept until 6:00am and then got up and started a new day. I didn’t know what the day would have in store but I did know there would probably not be many dull moments.

***For more photos from the field, you can follow me on IG @globalmidwife64 ***

Flooding, twins and life: South Sudan 2 months in

Only four months to go on my current assignment. Sometimes it feels like I have been here forever and other times like I just arrived and where has the time gone! It can be pretty exhausting and although I have wanted to post sooner, when I have down time (infrequent) and I have the choice of internet or sleep, sleep always wins.

It is about 104° here but the humidity is much less most days so it is way more bearable than it was when I first arrived. On 30 October, the South Sudanese government declared a national state of emergency. Thousands of people were displaced, including many of our local colleagues, who lost their homes, crops and livestock. To respond to the health needs, an emergency team was deployed from HQ and they joined us in our compound. This means that we have gone from about 25 expats in the compound to more than double that. There are people everywhere. What little privacy there was before is virtually non-existent and honestly, that has to be the worst part. The food is abundant and probably the best I have had on an assignment. My tukul is comfortable. Most of the time the internet works even if the majority of that time the signal is weak. Still, I really cannot complain, although it has literally taken me 3 days to try to write, edit and post this due to the painfully slow internet and now it is 4:30am and I am awake having coffee writing this because no one else is online and less demand means faster internet!

Flooding from the Nile has affected the entire area in and around the refugee camp.

The flooding around the refugee camp is quite impressive. The UN has brought in large earth movers and they have made dikes all along the road to keep the rising water from washing out the road to the airstrip. So far they have been successful. The airstrip itself is at risk of flooding in which case we would not be able to land any aircraft. At that point they would likely start to evacuate us by helicopter, which is the emergency plan at the moment. Without the airstrip functioning, we would not get our food which is flown in twice a week. We also would not be able to evacuate for a personal medical emergency. But evacuation is a last resort and seems unlikely.

This morning we had a twin mom birth. She had 5 births prior to these 2. She labored all night and into the morning and was finally ready to push just before noon. The first baby was a girl and she came head down. The second baby was a boy and was presenting transverse. After a few tries to externally turn the second baby to no avail, (arm was persistently in the place where the head should have been) I went in after the feet instead. First I broke the bag of waters; the heart tones were dipping and we wanted to get the baby out. He was pretty resistant to my grasping his feet and kept pulling one foot back up. Eventually I got a hold of both feet and was able to bring the baby down and out just past the hips, at which point I asked the mother to continue to push. The left arm was born but the right one remained very high. I did a side to side maneuver after disimpacting first. The baby came down low enough that I could bring the other arm down, and with that the head came as well. Both babies were in excellent condition and were 2.9 & 3.0 kg respectively. Two placentas came about 30 minutes later and there was minimal bleeding. All three are now resting on the ward.

A flight coming into the airstrip with a patient.

Once or twice a week we get patients flown in from other projects because we are the referral hospital. Sometimes I go to meet the flight when there is a maternity patient because someone from the unit has to go. It is actually nice to get out of the compound and see what is surrounding me because there is no way to see out. We actually live in a compound within a compound. It is easy to commute to work because I just walk out of our expat living compound and right into the hospital area. Both the hospital and the living area are housed within the UN compound. About 200 UN soldiers live next door, although we never see them, the wall is too high.

A patient that was flown in several weeks ago, came with his pregnant wife as his caregiver. This week, he was officially discharged by the surgeon. He had been shot and had his leg amputated above the knee. A lot of limb amputations are done here and most are for gunshot wounds. Keep in mind, patients usually do not get to us right after their injury, sometimes it is days or weeks. The happy ending to this particular story is that the evening before discharge, the mans wife came into maternity in labor. She birthed a beautiful, healthy baby girl. Spouses are never in the birth room when women are giving birth and this was no different. The man was still on his unit in his bed. The mother was getting washed up from the birth, so I bundled the baby up and with the moms permission, I walked to the next unit with the baby and placed her in her fathers arms. It was incredible to see the absolute joy on his face as he held his daughter. The entire ward was overjoyed actually.

Another patient flown in was a 22 week pregnant woman with severe polyhydramnios (too much amniotic fluid). This was her 7th pregnancy. The baby, on ultrasound, also had hydrocephalus and what appeared to be some pretty severe facial deformities – we could make out one very large eye socket. There would be no way to continue with the pregnancy because of the strain of the ever increasing fluid on her uterus. She was a very tall, slight woman and looked like she was carrying full-term twins. It was impossible to palpate a baby inside because her belly was so hard, nothing could be felt. She was also miserable. It was painful to be upright and walk around and it was painful to lie down and also difficult to breathe.

We don’t really have guidelines for this type of scenario so I had to be creative. Keep in mind also, there is no OB on the project. We have a general surgeon but there is no one but me managing the complicated OB cases. I have the help of the maternity staff but I am required for all the high risk and more complicated case and decision making. So my decision in this case was to drain as much fluid as I could and then induce labor. The baby was not viable at 22 weeks but it also had anomalies incompatible with life, which was explained to the mother. She agreed to our plan.

I asked the surgeon if I could use the OT to do the amniocentesis (fluid drain) because it really needs to be done under sterile conditions and the OT is the cleanest place we have. He didn’t mind at all. So early in the morning, I took the patient in and put a needled into her abdomen where there was a large pocket of fluid and drained about a litre. I had wanted to drain more but it just wasn’t coming. I had hoped for about 2 litres even though there were at least 6 litres, draining too much at one time isn’t safe, this is why we didn’t just break her water.

We started an induction with misoprostol that evening in the hopes of softening the cervix and maybe start some mild contractions. She was only 22 weeks pregnant so I wasn’t sure how easily her body would respond. Much to my surprise, after just the first dose of misoprostol, her uterus began to contract. In less than 3 hours she was in the birth room pushing. I had the staff prepare for hemorrhage, which seemed pretty likely given the circumstances. Because had birth several times before, she was a good birther. I was able to break the bag of waters and the baby’s tiny feet presented pretty soon after that. Then the body came. We could see already the baby had died and I was relieved that I would not have to watch a 22 week baby struggle to live once it was out. I have done that before and it just isn’t pleasant.

In this case I knew the head was going to be an issue because it was so large and misshapen. Once the body was out, I went in after the head which, once I got inside, was not discernible at all. There were no defined skull features, this wasn’t going to be easy. The mother was tolerating all the invasiveness, she was quite committed to get this over. I did the best I could to scoop what I felt was head and a large mass of tissue came out. I went in again to get the placenta and that too, was quite large and misshapen. When all was said and done, we were looking at nothing I had ever seen before. The head was completely malformed and much larger than a term baby’s head but as I said, it was all misshapen and there was no skull so it was all basically soft tissue. The placenta was much larger than a placenta at term as well. And it wasn’t very defined and basically looked like ground beef and not a placenta at all.

The mother did exceedingly well. She lost a minimal amount of blood, much to my relief. I looked at her afterward and said, you did a great job. Although I don’t speak her language, somehow she understood what I was trying to say and she gave me a huge smile and a thumbs up. I could see just how relieved she was to have it all over; not just the birth but the pregnancy itself.

Finding was to cope with the stress and not-so infrequent tragedies isn’t easy but I do find my way. My staff surprisingly understands my sense of humor, which can be dark and/or sarcastic at times. But each time they laugh at me, I am delighted. They also make me laugh. One midwife asked me the other day, “how long have you been wearing that skirt?” I wasn’t sure if he was asking days, hours or what. So I asked why he was asking. He said, “because it looks like it is from the 80’s!” I burst into laughter. Fashion advice in the middle of a refugee camp in South Sudan!

We have a lot of anemia so we do a lot of transfusions. It is not uncommon for a patient to walk in with a hemoglobin of 2 or 3. Families have to donate for any patient that needs blood and it is more difficult than it sounds. Sometimes you can have 5 willing donors and only 1 of them will pass the screening to donate even though you need 2 units. Often patients have to get by on just one unit.

Currently we are out of the reagent that goes with the hepatitis C test, so we can’t screen for it. It is one of the many things we screen for with the donors. So this has put donation at a screeching halt. Our bank has only a couple of units of blood left as we wait and hope the reagent is found and sent from Juba.

This is life here. Challenging, heartbreaking, stressful and unbelievably rewarding.

A Wake-up Better Than Coffee: One Morning in a South Sudan Maternity

South Sudan is hot. It is an average of 40°C (104° F) every day. The cold showers are so refreshing and it feels great when first stepping out all clean and cooled off. Then, within about 10 minutes, you are a sweaty, disgusting mess again and you just learn to live with it. It isn’t so bad after a while.

Days like today, when I am woken up at 5:30am to a radio call from maternity, I don’t even get to brush my teeth or have my French press coffee let alone take a shower, because yes, even asleep, by morning, you are a disgusting, sweaty mess. This particular morning, the call was, “Patient referred from another facility with cord prolapse and we have a patient with APH” (hemorrhage during pregnancy). So there were 2 critical patients. Nothing wakes you up better than coffee, unless it is a cord prolapse and an APH!

I threw on some clothes and ran down to maternity. As I expected, I found a woman in the birthing room with an umbilical cord hanging out of her. It looked fairly full and blue. I quickly grabbed the doppler and found a nice fetal heartbeat. I told the midwife that the baby must be breech and indeed, on exam I felt a butt and two feet. The cervix was gone and I told her she could push when she felt like it. Soon, the bottom emerged and the feet along with it – he was a BIG boy! The baby came out with perfectly crossed legs. He didn’t rotate completely and his arms had not come down. Due to the prolapsed cord, even though that one set of heart tones were good, I didn’t waste time waiting as I would normally do, so after the next contraction, I did a side to side maneuver which released one arm, the other was still up, and I reached up and brought it down. The head came all the way down easily and then he was born. He was a big boy! I did a little resuscitation to bring him around and he did well and by the time his mother delivered the placenta, he was ready to nurse.

A little of what we deal with on a daily basis.

In the meantime, there was the APH patient and while I was helping attend the breech, I was calling out instructions and asking about that patient. She was in bed 8 so I knew she was the patient with placenta previa. The bleeding had basically subsided but we still needed to get her into OT. She was about 33 weeks and we had been hoping to get her a little further along when we admitted her a day prior before having to take her into surgery. But we had given her 2 out of 4 doses of dexamethazone to help with the baby’s lung maturity in the event she did need surgery sooner. That was a good call. So the staff prepped her for the OT while I called the surgeon on the radio. In no time at all she had 2 IVs, a urinary catheter, blood type and cross and her husband sent down to donate blood at the lab. Patients always need to bring donor with them if they are going to need blood.

During the time that mother was in surgery, we also had a VBAC mother give birth – she had had 2 previous c-sections. We had another mom birth a baby born in the caul, and then that mother proceeded to hemorrhage. All of this took place between 5:45am and 8:00am. I was tired before the day even began.

The surgery was a success for both mother and baby and she is recuperating well on the ward now, although she did have a fairly significant blood loss and her hemoglobin fell to transfusion level so she got a unit of blood. The baby is tiny but doing as well as can be expected at such an early gestation.

The VBAC mother was discharged the next day as was the mother with the breech baby. We kept the mother that had the PPH an extra day just to make sure she was strong enough when discharged; they go back to the camp and life is neither relaxing or easy. There were several other patients during this time as well, including a young woman pregnant with her first baby who was hospitalized due to a domestic violence incident. There was a patient with a molar pregnancy, we usually have at least 3 per week. There was a 16 year old with a 26(ish) week demise, her first pregnancy. We have a mental health department so I made sure that she was referred to that department prior to discharge. We also had a woman birth who was HIV positive and her baby is now receiving ARVs.

There is very little downtime in maternity but we do find small pockets of time to sit down and “take some tea”. The staff is made up primarily of young men and women, most of whom have not even been alive as long as I have been practicing midwifery. They make me laugh every day and they frustrate the heck out of me every day. Such is the nature of this work and the learning curve that comes from being a new expat on a project. I wouldn’t have it any other way.

South Sudan: One Week In

Where to begin? Aside from the ungodly heat for which it is famous, South Sudan is the worlds newest country, having gained it’s independence from Sudan in 2011 after a 22 year civil war, one of the worlds longest civil wars. There has been turmoil in this region for decades and it is basically one giant humanitarian aid project. This is evident immediately as you descend into Juba International Airport with a view of rows and rows of every kind of aircraft imaginable sporting logos of every humanitarian assistance program imaginable, including UN, IRC, MSF, RCRC, ICRC, WFP, USAID and on and on.

At independence, South Sudan was grappling with at least 30 humanitarian emergencies. Parts of the country were engulfed in increasingly fierce intercommunal clashes, and there was renewed conflict in border areas with Sudan. Despite the challenges, the first years in the post-independence period were a time of optimism and it was a period of relative peace for most of the country.

However, by December 2013 – less than two years after independence – the country had rapidly imploded into a new civil war, exposing the fragility of the newfound independence. The conflict is estimated to have led to over 400,000 deaths to date, many the result of ethnically motivated targeting of civilians, including children and the elderly. Sexual and Gender Based Violence (SGBV) has been used as a weapon of conflict.

Some of the most extreme violence was conducted in places of refuge and sanctuary, including state hospitals, where patients and people seeking shelter were killed in a series of brutal attacks. Millions of people have been displaced, often multiple times, inside and outside South Sudan. This includes hundreds of thousands of people who sought shelter in Protection of Civilian (PoC) sites, inside the bases of the United Nations Mission in South Sudan (UNMISS).

A view of the POC camp from the commuter plane. The camp itself is shaped like an ‘L’, the rest is UN compound, MSF compound and hospital.

I am currently in a PoC camp with a census of 108,000 at last count. Our hospital serves this entire community and although there are other organizations providing healthcare, we have the highest level of care which includes a surgical unit, NICU, TB isolation ward, COVID isolation ward, and all the rest, like maternity and general medical wards. We currently have about 160 patients admitted.

Our compound has roughly 30 expat staff from around the world and we live right next door to the hospital. This means at night I can sleep in my own bed and the maternity staff can call on my radio and I can be in maternity in under 2 minutes. There are about 500 national staff, all of whom are IDPs themselves and they live in the camp.

Surgery is available 24/7 and we have one surgeon. For this reason, the expat surgeons have short assignments – 6 to 12 weeks usually – due to always being on call. Although the surgeon can do Cesarean sections, our rate is about 5-7% given the month and for maternal indication only, so our section rate remains low. The maternity is a referral center and patients have to meet a high risk or emergent criteria to be here. They are referred from other clinics inside the camp or from other MSF projects in South Sudan, and flown in. What this means is, that regardless of how many patients we have at any given time – usually 8 to 10, most are quite sick and/or high risk. There are occasional patients that shows up as self referrals in labor and if they are too far into it, we keep them. Otherwise we send them to a nearby clinic because we don’t have the bed space for patients who are not critical.

We do not do any kind of antenatal care, so we don’t have the usual line up of women waiting to be seen. Anyone in outpatient (OPD) is there because they are pregnant and unwell. We do not do postpartum care beyond the time they are hospitalized, they go back to their primary clinics for that. We treat a lot of malaria in pregnancy and most of those cases are outpatient. I manage 15 midwives and of these, about half are men. There are usually 2 midwives on shift, 2 in maternity and 1 in OPD during the day. There are 2 that manage everything overnight. There is a midwife in our family planning/SGBV/ToP clinic. She is stationary and manages the sexual violence cases, and all family planning. I support her as well. On weekends when she is not working, I manage those cases that come in along with one of the maternity midwives due to the language barrier.

NICU is a separate ward across the corridor and I have no staff in that ward but I am responsible for helping in emergencies, referring babies from maternity to the NICU and collaborating with them on care of the babies that are admitted. There are no babies past 6 weeks in that ward. This week we have had 3 preterm babies born.

In less than a week I have experienced and managed a great deal. There have been 2 pregnant women with hemoglobin of 2.3 and 2.7 respectively. One was second trimester and the other 3rd. Each were transfused. The one is still pregnant and the other gave birth to a stillborn male at about 24 weeks gestation. He came out into my hands completely encased in the caul with the placenta attached, a perfect oval package. There was no bleeding whatsoever and the demise had been very recent.There are 2 patients with polyhydramnios and one is quite severe. Her gestation is 21 weeks and her baby is hydrocephalic and has other facial anomalies. The other is 26 weeks with an anencephalic baby – so both babies have anomalies incompatible with life. Both are being treated this week and I will write about those cases in a later post.

There have been 3 cases of gestational trophoblastic disease (molar pregnancy). All were about 16 to 20 weeks. After termination, we follow these cases for a year due to the risk of the GT turning into choriocarcinoma. Gestational trophoblastic disease at an advanced gestation like 20 weeks, which all of these were, is very rare, but not uncommon in environments such as these when prenatal care is often not sought or is not received until far into pregnancy.

Currently, there is a patient with gestational gigantomastia. She has a very small frame and I cannot imagine the pain of having breasts the size of watermelons with virtually very little in the way of treatment options. Another patient is 4 months pregnant and being treated for wounds on her thighs and buttocks from a beating sustained from her father.

We saw several cases of SGBV this week, as gender-based violence is quite common in places like refugee camps due to the extreme stress and crowded conditions. The stories are quite disturbing and often it is intimate partner violence for which not much can be done to keep the woman safe in the future.

Because there is no obstetrician or gynecologist on staff, I guide the staff in management of all difficult cases that present. There is nowhere else for the patients to go, so this is how it is. I will write more in the coming weeks about specific cases and the challenges surrounding them. I have already seen some of the most challenging cases of my 32 year career and I am more and more grateful for my time in Afghanistan and all I learned there because this is going to rival that but in a much lower resource environment with less support staff. It requires patience, creativity and more than a little tenacity.

Stories from Afghanistan

I am frequently asked what my favorite country to work in has been, so far. When I am on mission, that place is usually my favorite place. I become immersed in every aspect of the work, country, and community. For me, the only way to get through months in a difficult context is just immerse and move in. I must embrace every aspect of the experience from the weather, food, living conditions, language and security, to the communication issues, workload, and of course, the tragedies; it is the only way I mange to get through some days. Some contexts are far more difficult than others, that is for certain. Still, when I am asked about my favorite place, I am usually between missions back home. Without hesitation, I respond, “Afghanistan”. People’s eyebrows shoot up, heads tilt, they respond in astonishment, “really?”, almost without fail.

Yes, really. I love Afghanistan. It is a brutal place, which is what most people imagine when they envision Afghanistan. But it is also ancient and beautiful, an ethereal beauty that almost escapes words. My only experience of the country itself, aside from what was outside my bedroom window, was the trip from Kabul to the mission and from the mission back to Kabul to go home. So, all I know of it, I know from a moving vehicle and my bedroom window. I fell in love, nonetheless.

Afghanistan is an Islamic Republic, which means that just prior to landing in Kabul, I had to get out my hijab and cover my head, it is the law. I was already wearing clothes which covered my arms and legs, also required. Kabul is, I suppose, what most people think of when they envision Afghanistan. And indeed, Kabul is a loud, over crowded city with helicopters whirling overhead like enormous dragon flies and the occasional explosion heard in the distance. Brutal. The traffic is awful, like any other large city. But its one redeeming quality is the beautiful Hindu Kush, jutting majestically out from the horizon. The Hindu Kush is a 500 mile stretch of mountains that run through Afghanistan, Pakistan and into Tajikistan.

Once out of Kabul, the terrain opens to a vast expanse of rocky topography and qal’ahs, the traditional mud houses that litter the countryside. The houses blend into their surroundings and look like part of the mountainside which makes for quite a remarkable effect.

I loved looking out my bedroom window or sitting out on the rooftop porch at our house and looking around at the seemingly endless expanse of mountains. I would never mistake these for mountains anywhere else, they have there own unique essence. And one must not be fooled by their rugged, bare terrain, they hide a secret. Emeralds. It delighted me to look at those mountains and know I was surrounded by a vast fortune in gems.

We were not allowed to post on social media for security reasons, so I never wrote a blog or posted about my experiences like I do now. As mentioned before, we were not allowed to go anywhere outside the compound other than next door to the hospital and we were accompanied there and back.

Here is an excerpt of what I wrote to a friend at about 2 months in: I am tired most of the time. My head hurts most of the time. It may be altitude, it may be stress. We attend 600 to 700 births a month. Everything and anything. Name a complication. Name a disorder or a malformation or birth defect. They have it all many times over. Meconium and hemorrhage, every day. Breech and twins many times a week. Last month about 26 breeches and 10 sets of twins. We don’t count the breeches that are with the twin births in our breech tally. Breeches come every which way and by now I have done and seen it all!

Here is what I remember: Cord prolapse, cord presentations, molar pregnancies, uterine rupture, uterine inversion, placenta previa, acreta, percreta, bicornuate uterus, polyhydramnios, oligohydramnios, chorioamnionitis, preterm, PROM, PPROM, retained placenta, abrupted placentas, obstructed labor, severe shoulder dystocia, breech extractions, interlocking twins, cervical head entrapment. Gestational hypertension, gestational diabetes, gestational trophoblastic disease, choriocarcinoma. Diabetes, fatty liver disease of pregnancy, HELLP, pre-eclampsia, eclampsia. Anencephally, hydrocephally, dwarfism, spina bifida, limb malformations, IUGR, LGA, severe post-term, and 20 week babies born that live for over an hour outside the uterus. Ectopic pregnancies, early and late miscarriages, missed abortions with hemorrhage, grand parity over 8, 10, 12, severe anemia that need transfusions. Then the babies that just fall out, cry, followed by their placentas and no bleeding. Dozens of those per week. I am only called for the high risk.

The Afghan women are simply stunning. I wish it had been appropriate to take their photos. The combination of dark skin and green eyes make it difficult to look away. If you have seen the photo of the 12 year old Afghan orphan, Sharbat Gula on the 1985 National Geographic cover, you know what I am referring to. I realized then that she was not at all unique. There were a host of people with the piercing green eyes all over South Asia and many of them came through our maternity.

In Afghanistan, as in many Muslim majority countries, women cannot make healthcare decision for themselves. They cannot really make any decisions for themselves. This means, we cannot treat a patient that comes in if we do not first have the permission of a male family member. Usually this is the husband but in his absence, it can be the father, brother, uncle or even sometimes a son – even a son who is still a minor can give authorization but a woman cannot. Even if the woman’s life is in immediate danger, staff has to run around looking for a male relative to put a thumb print on the paper authorizing us to treat.

The maternity is staffed with 6 to 8 national staff midwives during the day. A little less at night. It was these midwives that I supervised. The majority of them were in their early to mid 20’s. Most had attended thousands of births. They had excellent clinical skills and were always eager to learn more.

My Afghanistan assignment has been the only time as a midwife where I could see a baby being born almost any time I wanted because we had such a high volume of patients. I would arrive at the maternity at 7:30 each morning and start my day by going into the area with the birth rooms. Usually there was someone giving birth and sometimes even more than one. I would stand quietly by and watch, just to see new life at the beginning of the day, knowing that the rest of the day could well bring anything with it and not necessarily good things. I would congratulate the mother and then join the rest of the team on rounds.

A non-pregnant woman came in one day and it was very apparent she was quite ill, close to death actually. She was pale, weak and severely underweight and we admitted her into the ICU after an initial evaluation which showed a hemoglobin of 2 (we would expect it to be more like 12). We started a blood transfusion immediately.

A full patient history was taken and a story emerged. The patient was in her early 30’s and had been married over a decade and had no children. After a few years of infertility, her husband took another wife (it is common to have multiple wives in Afghanistan) and that wife produced children. Infertility is a shame upon the family of the woman, because they were paid a lot of money by the husbands family, so it is seen as a kind of reneging. Another wife was taken a few years later and more children came along. In the meantime, the patient was relegated to the role of a servant. She did the chores, cooked, took care of children with the other wives but she was also not fed adequately. Food scarcity is fairly widespread in many parts of Afghanistan. When there is food, the men always eat first, then the children, then the women. This woman was the very last in the pecking order. She was unable to produce offspring and in Afghan culture, if you cannot bear children, you have no value. They ignored her suffering for a long time and so it wasn’t until she was very close to death that they brought her for medical care. Keep in mind, the care is FREE. They were not trying to get out of paying for treatment, they just didn’t care.

Eventually she began to feel better after several units of blood. We kept her for a few days while she gained some strength back and then she was discharged. I often wonder what has become of her since her situation is not likely to change.

The unusually empty ICU which did not stay that way long. I think it was about 30 minutes.

It was not uncommon for us to see girls as young as 12 come into the maternity hospital. Families will marry off their daughters if they are in need of money and find someone willing to pay the bride price. As you can imagine, these girls are terrified and barely understand what is happening to them. They have all suffered trauma just by virtue of the fact they were married off at such a young age, some to much older men. We also saw cases of extreme sexual violence of girls and women brought in within a day of their wedding. Most often the violence was caused by the mother-in-law of the bride, making an incision, basically an episiotomy, to make sure the marriage was consummated. Most of the damage was severe enough that it required general anesthesia for the surgical repair. It was the humane thing to do.

We had many multiples born each month. They came in every presentation imaginable and most of them were vaginal births because we did not do Caesarean’s routinely. Presentation of the twins was not a deciding factor as to whether the birth would be vaginal or not. If there was a failure to progress or an arrest of descent and it was clear these babies were not going to be born vaginally, then we would refer for a c-section just as with a vertex presentation. So when we had a breech/vertex presenting set of twins, we proceeded as usual although many providers would risk that combination out. I experienced 3 such sets during my time there. It is one of the more uncommon twin presentations. All 3 sets were term. Two proceeded without any issue and the third I determined was likely to have an issue because the babies were facing each other. Those babies did become locked as the first one descended but I was able to manage and I will write about that birth in a separate post.

Afghanistan is a multiethnic and mostly tribal society. Dari and Pashto are the official languages and are fairly widely spoken but there are other languages and dialects in different regions of the country that are spoken by different tribes. There were times in maternity when the staff didn’t understand the patient because they didn’t speak a language familiar to anyone on staff. So sometimes, if there was a younger family member available, we would bring them in to interpret because they usually spoke Dari or Farsi. This happen mostly with the Kuchi people. They are nomads but there are many different tribes. Kuchi actually means nomad.

The Kuchi women were incredible. They would come in in these incredible clothes, layers of skirts, headdress, cloth and blouses adorned with elaborate beadwork, sequins and ornate embroidery. Their jewelry was equally impressive with a multitude of necklaces, heavy dangling earrings, nose jewels, rings and exquisite glass bracelets. They made noise when they moved due to all the adornments. They have marks on their faces called khals. The women have been doing pin and ink tattoos like this for centuries. It is believe to be pre-Islamic. They are rites of passage. All the women looked like they had just walked off of a movie set. I marveled each and every time one came in and the staff found this amusing.

Because of their nomadic lifestyle, they are very hearty. The woman are stoic and strong. They make not a peep during labor or birth. The Italian obstetrician on staff who had been there for 11 years said, “you will never see a Kochi woman have a c-section unless it is for something like an abrupted placenta, an emergency. But never for obstructed labor or failure to progress or CPD. Never.” And she was correct, no Kuchi woman ever had a c-section during my tenure there.

I remember vividly an older woman coming in with preterm labor. Her baby was about 20 weeks from what I recall. She had several children already and would birth this tiny preterm baby with no difficulty. We did not know why she went into preterm labor but I did know the baby was still alive, just not viable. Whenever we had someone who was going to birth a preterm, non-viable baby and I was on shift, I always asked to do it. The midwives were perfectly capable of managing but I knew they would be more matter of fact and less compassionate because that is just their way. It is a very busy maternity. There was always a staff midwife with me because we worked in pairs and they were there to learn.

I noticed when they attended preterm births of non-viable babies or stillbirths, they severed the umbilical cord and put the baby to the side for the cleaner to wrap in muslin and take to the morgue and later give to the family for burial. Then they would turn their attention to the mother and the placenta. And that was that. I asked them if they asked the mother if she wanted to hold her baby. They dismissed that notion. They always said the mother didn’t want to. But I then I would say, “the question was, did you ask her? No, they had not. So I explained to them that they should not just assume the mother doesn’t want to hold the baby, they need to ask because even if most do not want to hold their baby, some will, don’t assume. Sure enough, when they asked, some of the mothers did indeed want to hold their stillborn babies briefly.

Some of these non-viable preterm babies actually came out alive and the midwives treated them the same as a stillbirth – they wrapped them up as though they were already dead and put them off to the side to be taken away by the cleaner to the morgue. Horrified and indignant, I explained to them they couldn’t do that! This was a living, breathing human being and although his time here with us would be short, he deserved to be treated with kindness and compassion, not be shoved off in a corner to die alone. The midwives would nod their heads, not really understanding this kind of reasoning but if I was on the unit, they would listen to me.

So it came to pass that when I was working, I held many a non-viable preterm baby, wrapped in a blanket, close to my heart so that they did not have to die alone. So they knew they were safe during those first minutes and last minutes of their lives. I don’t know how many times I did this, but it was a lot. No one should die alone.

When the older woman in preterm labor gave birth, her baby moved, made little crying sounds and fought valiantly to try to stay as long as possible with us. At 20 weeks, it would not be long. I asked the midwife to ask the mother if she would like to hold him. I told them to explain to her there was no possible way he was going to survive for long but he was alive right now. She wanted her baby. I wrapped his tiny little perfect body up in a much too large for him blanket and handed him to her. She cooed at him all while we removed her placenta and cleaned her up. Then it was time to go to postpartum. But women who lost babies were put in the general medical/post-op room so they didn’t need to be with all the mother with babies, adding insult to injury.

The girls that walked past my window every day.

We moved her and her tiny little boy whom she cradled closely, seeming to not see anyone else in the world during that time. She cooed over and over, “joon, joon”, at him. Joon can mean ‘life’ or ‘dear’ in Farsi. Over and over I could hear her as I moved through the ward. I kept going back every few minutes to put a finger on his chest to check for a heartbeat and every time, there it was. I was astonished. I could not believe how long this baby was able to survive with nothing supporting him at all, except the love of his mother.

The OB residents came into the ward to check on someone else and asked what was going on. I explained about the 22 week baby, his birth and that his mother wanted to hold him. The one resident smiled at me in a mocking way thinking this was the most ridiculous thing she had ever heard. She didn’t believe the baby was even still alive. She peered into the blanket and felt the heartbeat and then rolled her eyes. She told me the baby was not going to live. I told her I knew that and the mother knew that but that he was alive now and she wanted to hold him and so she was! Finally the resident took her judgement and moved on.

I stayed by that mother so that no one could disturb her or her little joon. I stayed until at last I felt no heartbeat and I told the mother. She abruptly handed him to me then and I took him away as she wept quietly in the ward. I prepared his tiny body which consisted of wrapping him in white muslin and tying it all up like a package. He would then be given to waiting family to take home for burial, which would happen very quickly. He had lived an entire hour!

My months in Afghanistan had a profound impact on my work and life. It was difficult, heartbreaking and beautiful. I am forever changed by it in ways I cannot even begin to articulate. I have enough stories from that time to fill a book, but I have decided it is better to space them out in multiple posts over a few weeks. It is a lot for me to dig up and process and I find it somewhat overwhelming. Still, I would go back in a heartbeat. Afghanistan challenged me to my very core and I have immense gratitude for that experience.

The Refugee Crisis No One Has Heard Of

When I arrived in Mozambique, it felt like I was in a South American country. It is a tropical paradise and one can feel the influence of the Portuguese that colonized this country long ago. Mozambique is beautiful and rich in history both interesting and tragic, like most African countries that have been colonized. Mozambique is in Southeast Africa and it is bordered by Tanzania to the north and South Africa to the south. The Indian Ocean is its eastern border and the countries of Malawi, Zambia, Zimbabwe and Eswatini border the north to northwest.

The population of Mozambique is about 30 million. It is one of the countries most exposed to climate change with temperatures rising twice as fast in southern Africa as the global average. Economically, Mozambique has many mineral resources, such as coal and rubies, but it remains one of the poorest and most underdeveloped countries in the world.

Natural gas was discovered in 2011, with 150 billion cubic feet of recoverable reserves off the coast of northern Cabo Delgado Province. Once developed, it could make Mozambique one of the largest producers of liquified natural gas in the world. Production by the Total company was scheduled to start in 2022 prior to the pandemic. Between the sporadic terrorist attacks and COVID-19, all that is on hold indefinitely.

Pemba, Cabo Delgado, Mozambique – the Indian Ocean

Despite its wealth of natural resources, Cabo Delgado is one of the least developed provinces in the country. Since the end of the civil war (1992), this wealth, particularly rubies, has attracted many migrants from Tanzania, Somalia, Senegal, Mali, Eritrea and Pakistan. The local Muslim community has been confronted with a wave of radicalization.

All political issues aside, the people are kind and welcoming. My national staff colleagues speak a gentle, easy to understand Portuguese. Mankua is the local language most commonly spoken by the people in the camps and when I speak to them, I speak through my interpreter as he fluent in Mankua .

Violence erupted in 2017, when an unknown group of armed men attacked civilians in the province of Cabo Delgado. Since then, several attacks have occurred in different cities around the province, displacing huge amounts of the population as they literally run for their lives. Many people have been killed, including children, some who were beheaded in front of their families. There are currently an estimated 800,000 people internally displaced in Cabo Delgado with camps spread throughout the province in the areas that so far, have remained untouched by the violence. In spite of heinous nature of these attacks, the people who have been killed and the sheer number of people displaced, this hardly makes the news. Most of my friends had no idea there was even anything going on in Mozambique.

I had been here just a few weeks when, at the end of March, there was another attack in a city north of here. Many people fled to the bush as the violence began. These attacks are without warning, so no one has time to gather even the most meager possessions or food. They flee on foot and spend days in the bush with no food or water. Eventually, some make it north to the Tanzanian border. Some make it to the shore where they flee in boats and sail further south to Pemba where we have our base.

They arrive terrified, traumatized, dehydrated and hungry. Some of them are injured. All arrive seeking refuge. Our objective is to provide medical assistance, stabilize patients and ensure the ones in critical medical condition get sent to on to a higher level of care. The primary goal is to save lives.

Children are among those who have fled. We cared for one baby with a bullet wound. Pregnant women are also among the wounded and traumatized. One woman who was about seven months pregnant had significant bleeding, probably a placental abruption; her baby had already died. Mothers arrived with day old babies who had been born in the bush after fleeing the terrorists, having birthed in very difficult and unsanitary conditions. Most mothers I saw were in shock, dehydrated and hadn’t eaten for days. Trauma and stress in combination with the food deprivation was enough to keep them from producing an adequate milk supply.

To say that treating people under these circumstances is gut-wrenching, would be an understatement. I really have no words to describe the level of trauma I see daily. Many of the women have experience sexual violence at the hands of the terrorists. Some of the women, now in the camps, experience domestic and sexual violence there as well. The stress, crowded conditions and food scarcity brings out the absolute worst in people.

Camp 25 de Junho, Cabo Delgado, Mozambique

Caring for the survivors of sexual violence is a big part of my job as it falls under sexual and reproductive health activities (SRH); it is also the least favorite part of my job but probably the most important. Together with the mental health team, we treat and counsel the survivors. The treatment plan for sexual violence survivors is the same in all project and consists of the following: pregnancy test, HIV test, emergency contraception, PEP (post exposure prophylaxis), STI prophylaxis, and vaccination for hepatitis B and tetanus. Men and boys are also seen in the clinic as sexual violence survivors and the same protocols exist for them except of course for pregnancy test and emergency contraception. The survivor has the right to decline any all treatment and testing and some do and only come for mental health services. We facilitate referrals when requested, to local authorities but do not get involved in the legal process aside from providing a health certificate.

There are days when working in the camps becomes overwhelming just due to the sheer volume of patients we see. Babies with complicated malaria, mothers with sepsis due to unclean birthing environments and children with severe dehydration from extreme diarrhea. There was a cholera outbreak which was ending just as I arrived. Now we are heading straight into malaria season.

Malaria is endemic to Mozambique and 100% of the population is at risk for it. Plasmodium falciparum, the deadliest type of malaria (there are 4 types) accounts for 42% of deaths in children under 5 years old in Mozambique. We use Coartem to treat malaria and we ran out about 3 weeks ago. Since then, we have seen a steady increase in complicated malaria among babies and young children.

My interpreter is from the north where the violence first occurred. He fled to the south as well and was able to find a job as a daily worker with us doing interpreting. He speaks Portuguese, English, Mankua and at least 3 other local languages. He shared some photos with me of his time hiding in the bush with his family. He said they went for 3 days without eating. When they came to a stream along the way, they were able to drink but didn’t know how long it would be before their next encounter with water so the women took one of their layers of fabric off and soaked it in the stream and then balled it up to keep it as wet as possible. They stopped periodically to take the fabric and wring it out into the children’s mouths so they were able to stay hydrated. Pure survival.

A woman waits at the entrance of the SRH tent for a prenatal visit.

This is the second time I have worked in a refugee camp, but the first time I am working in mobile clinics. This assignment is much more resource poor than the last. The care we can give is very basic and anything more complicated must be referred to the nearest health center, which is also basic but with a few more resource than what we have, including the ability to treat people on an in-patient basis. The mobile clinics only operate from 9 to 3 Monday through Friday.

Working in an unstable context with the constant threat of violent attacks makes it a little more difficult to completely relax when we are back home after a long day in the field. For this reason, emergency missions are shorter (average 3 months), because they tend to be more stressful. Although we do manage to find reasons to celebrate any chance we get. Birthdays, expat departures, a national holiday are all cause for celebration which consists of gathering around the pool, having a BBQ, playing loud music and dancing.

This week marks the halfway point in my assignment. There is still a great deal of work to accomplish in that time and probably an equal amount of human suffering to witness. As daunting as the prospect is, I think about what Mr. Rogers said his mother told him as a boy about scary things happening, “Look for the helpers. There are always people who are helping.” And I know I can go on because, that’s us! We’re the helpers! We can’t let Mr. Rogers down.

The Matronas of Mozambique

Today I had the honor of facilitating a training of 8 Traditional Birth Attendants from Macomia and the surrounding area. TBA’s are known as ‘matronas’ in Mozambique. MSF is dedicated to supporting them with capacity building as they are the only ones left taking care of the entire pregnant population since the insurgents made it to Macomia and all hospital staff fled. We provide transportation to them and they come to Ancuabe, about 2 hours south and we do the training there. It is too dangerous for us to try to stay in Macomia at this time and Ancuabe is halfway between our base and Macomia so we meet in the middle.

Matronas are chosen by their communities to serve. Many of them had a mother or grandmother or both, who also were matrona’s and they were handed down the knowledge from them. They are well respected in their communities. They are usually illiterate and have no formal training at all, although there was one young matrona, 25, who had an education to grade 12 and could read and write and speak Portuguese. Unless one has been to school, only the local language is spoke. In this case, the local language is Mancua. Portuguese is taught in school. Matronas are not paid for their work, not even in barter but a few reported being helped out at their farms by women they had served.

Fatima attended the class with her daughter, Euclauzia.

When I do these types of training, I like to get to know the participants and hear about their lives and understand the challenges they are facing. These women were truly amazing. They spanned in age from 25 to 80 with all but 2 being over 50. Although, other than Fatima, the 25 year old, they didn’t know their specific ages, they only knew what year they were born and then told us and we did the math for them. They were kind of amused to learn their ages. They had over 150 years of experience between them. Most had been midwives for many years with the longest being 51 years. I enjoyed hearing about their lives and they asked questions about mine as well. I learned that every single one of them had lost at last one child and some of them had lost 4 or 5. Most had given birth close to a dozen times. The childhood deaths were due to malaria or diarrhea and one of the women lost an adult son 2 weeks ago when the insurgents raided the village where he and his family lived and he was killed with a machete. He left behind 3 children of his own who managed to flee to the bush with their mother.

These women have seen a lot. I listened intently as they each told stories. I asked about traditions, superstitions and rituals surrounding pregnancy and birth that were specific to Mozambique. I am not completely sure they understood what I was asking and only because I am fairly certain they don’t even realize some of the things they do are superstitious or ritualistic as they have no frame of reference. I gave some examples from other cultures. They said pregnant women cannot eat rabbit or octopus (Mozambique has the Indian Ocean as its eastern border). It would not bode well for a baby if the mother did this although they could not say exactly what would happen because no one dares do these things! I asked if men ever attend the births, although I knew the answer already, and there was a resounding NO! This was against their culture and also, if a man attended his wife’s birth he would run away after that and she would never see him again. Men are not supposed to be seeing “that”. I also learned the average age of marriage for a girl was 13/14.

They asked me about what is done in my country that was a ritual etc. I really couldn’t come up with anything specific but I told them that a lot of women like to listen to music while they were in labor because they felt it helped relax them. They thought this was hilarious and there was uproarious laughter when the interpreter finished translating what I said and then they asked if it was to drown out the screaming. I did tell them that men routinely attend their wives births. They marveled at the fact that anyone was still married in the U.S.!

One of the older matrona’s has blue eyes. I asked her about this. I wanted to know where they came from. She answered, “I have seen a lot.” Good enough for me.

The presentation was on Power Point with as many pictures as I could manage to find. What little text there was, Fatima, the matrona who could read, read in Portuguese and then told the others what it said in Mancua. I asked questions and made comments through my interpreter. The topic this month was danger signs in pregnancy. We discussed each danger sign and their experiences, if any, with them. They have a better understanding of the causes and when to refer, although, as they pointed out, the hospital has been abandoned so there is nowhere to refer at the moment.

When discussing anemia, a huge problem in most African counties, there was not a lot I could offer them. Generally I would have them refer to the health clinic for iron tablets and discuss dietary support, but again, they pointed out they have little access to food, including rice and flour and certainly there is no poultry, eggs or meat. Food insecurity has been a huge issue since the insurgency began. I had little to offer as they said most of the pregnant women were living off of cassava leaves, which happens to be rich in iron and a staple in their diet because it grows everywhere so it is plentiful. So they are currently doing all they can do.

The matronas do no prenatal care, they only attend women in birth and general will go the next day to check on the mother and baby. They are called to a birth when the woman is about to birth generally. They have been provided with non-reusable kits they bring with them which consist of soap, gloves, an apron, small plastic sheet, 2 small towels, 2 cord clamps or ties, and a sterile razor blade. They have no neonatal resuscitation skills. They said if a baby comes out not breathing, they wiggle the cord back and forth at the base where it attaches to the baby, fan they baby with something to move air and if those things do not work they assume the baby has died. So without any supplies at all, I gave an impromptu baby resuscitation basics. I told them next time I would try to find a doll to bring so I could better demonstrate. They do not have Ambu bags so mouth to mouth is the only thing possible in this environment and there are a lot of diseases to be concerned about, COVID-19 being the least of it!

Then came the singing! When I finished my presentation, they collectively burst into song, which is what all TBA’s throughout Africa are known to do. It was wonderful and energizing and when they finished, I clapped and laughed and they saw that it really brought me joy and this made them happy. We are off to a great start so far. I will see them again in a month for another training. They requested I cover complications during labor. Anything I can teach them that only requires their hands, I will teach, since they have no access to medications of any kind. The next class happening will depend on the insurgents and how far south they come, things are changing here moment to moment and we adjust security and movement accordingly.

Being in Ancuabe, away from the base in Pemba, has been interesting. It is quiet here. It is just a simple village with no ambient light at night so the stars shine bright without light pollution to dim their shine. I hear crickets from my bed at night where I sleep under a net, safe from mosquitoes. In the morning I lie in bed and listen to the birds welcoming another day in Mozambique. Tonight I am sure I will sleep well because it was a long day, although very fulfilling. I imagine I will think about the matronas and wonder how many of them are venturing out in the starlit sky to greet yet another baby.

https://anchor.fm/journeytomidwifery/episodes/Kristine-Laurie–Midwife-Without-Boundaries-etjgdg

P.S. If you missed the podcast interview on Journey to Midwifery with Amber, listen at the link above!

Cord prolapse, anyone?

Some people are just meant to be here. I walked into maternity this morning and heard noises from the birth room. I popped my head in just to say I was here and to ask if they needed anything. I was greeted back with, “Cord prolapse, breech.”

I stormed into the room, threw my backpack down at lightning speed and went to the side of the midwife to see a baby hanging from about mid-chest, with arms still up inside. The mother was on the delivery table and the baby was facing almost completely posterior. (I’m giving details for all the birthy people out there but in enough lay terms that everybody can understand, so if both camps could please forgive me that would be great.)

I quickly started asking questions–keep in mind my interpreter is not in yet– How long has the baby been like this? Just now. I look at the clock: 7:26. I looked at the cord, it was blue, like it should be. Baby looked white and floppy. I watch the midwife and she’s doing nothing but yelling at the mother to push. The hands-off approach is always best with breech unless you have an issue.

I said to her, “First you need to rotate the baby.” The problem was the baby was almost completely posterior and was not going to come down any further in that position; his arms would be hung up on the pubic bone. I could see she didn’t understand me so I got gloves on. This was a race against the clock.

I gently grasped the baby with my hands in a prayer position, one hand on the chest and belly and the other hand on the back, and I said to her, “First disimpact (which is pushing the baby gently back up just a bit) and then rotate.” And I slowly and very easily rotated the baby to sacrum transverse, at which time it came down to its armpits and went anterior. Unfortunately the maneuver didn’t release the arms as it sometimes can, but at least now we had the baby in the proper position.

Because I walked in on this drama and my assessment was that the baby needed to come out immediately, I then showed the midwife how to go up with a finger and sweep down the arm, then rotate and do the other arm (Suzor’s maneuver), verbalizing everything for her.

Then I saw the head was still quite high up and immediately saw the reason–the cervix. She was not fully dilated and the head brought the cervix down, so it was trapped like a tight reverse turtleneck. I was not happy. The only thing to do was go up and get the trapped head. It was difficult to get in around the cervix with my fingers, but I managed to get up to the mouth to flex the chin down all while the midwife was giving suprapubic pressure. I had my first and third fingers on the baby’s shoulders on either side of his head doing a downward press while the middle finger flexed the head forward.

The baby was lifeless and I had no hope of getting it out alive, but it had to come out. Then he took a breath! My finger inside kept enough of a space for him to be able to take another breath. It took gentle rocking to bring the head down far enough and past the cervix where I could then gently lift the body and it popped out.

I looked at the clock: 7:30. We cut the cord immediately; it was looking pretty anemic by then. As I brought the baby to the resuscitation table, where the second midwife was waiting hopefully with the ambu bag, I said, “He’s not going to survive.” She said, “The heart rate is low,” as she listened. I couldn’t feel a pulse at the umbilicus. I started chest compressions. Just mere seconds brought the heart rate over 100. I suctioned the nose and mouth and then started bagging the baby. His lungs filled with air several times, his color improved.

Then I turned him on his side and rubbed his back vigorously, and his eyes popped open and he let out the most beautiful wail. He was completely pink in an instant but not moving his arms or legs. We did all of our midwife things like weigh him (2kg), give eye drops and vitamin K. Soon his little arms and legs were all working symmetrically.

Later when I asked to take a photo, he smiled at me. As I held down his blanket for the pic, he grabbed out and met my finger and grasped it. All day long I was just in utter shock that not only was I able to get the baby out but that he survived against all odds. And although I’m not an expert, I would say this baby was as healthy as any baby could be. He cried, nursed, looked around. I estimate his gestation at about 34 weeks.

I did apologize to him for saying I thought he wouldn’t survive right after he came out. At the time it was more about my faith (or lack thereof) in my abilities and I didn’t really factor in his will to live, which obviously I greatly underestimated.

After the birth I got the back story of what had happened before I got there. The mother had come in at 6:00 a.m. with a cord prolapse. They found her to be 4cm dilated. They called a referral hospital who, long story short, just gave them the runaround. In the meantime, time went on and suddenly there were feet and then the legs and the body and then I walked in. Up until that time the heart tones had been good and the cord had been fat and blue.

A cord prolapse is not always necessarily an emergency, particularly when you have a breech. The cord can easily slip down between the legs as the cervix dilates. It isn’t being compressed, so it isn’t causing any harm to the baby. But it is a little disconcerting to see a cord hanging out of someone when you know it’s not supposed to. And because this baby was premature, the cervix did not dilate completely but the baby started to come anyway. I estimate the cervix was dilated to about 6 or 7cm at the most.

It was really interesting getting that head out from the trapped cervix. It was a very different maneuver than trying to get the head out of a bony pelvis. It required a sort of rocking motion.

I told his mother to come back in 7 days when he has a name and tell me what it is. The mother was so happy, all day long she kept saying how the baby looked like me, because we both had no hair! What could have ended up as an incredibly disastrous and horrible Monday, ended up to be one of the best days here so far. There are so many limitations, tragedies, and ways to feel inept and ineffective day in day out here, it feels really good to actually help someone. Monday was a good day.

Birth in the Rohingya Refugee Camp

The language of birth is universal. I have had the privilege of working with birthing women all over the world. A good majority of the time I cannot communicate verbally with the women giving birth because their language is not one I speak. At times it can be challenging and even frustrating but it has helped me tune in and listen to the language of birth, which can be very nuanced at times but if you listen closely it is easily understood.

This past week, I was working in the Rohingya refugee camp in Bangladesh; this is my current mission with Médecins Sans Frontières (Doctors Without Borders). We have a maternity service that serves about 50,000 of the 900,000 refugees in the camp. We see over 1800 patients a month and attend approximately 70 to 100 births depending on the month. The refugees speak Rohingya dialect and the midwives speak Bangla. I speak neither.

Breech birth is commonplace here, as it is in most of the developing world. There are no discussions of ECV or cesarean section; it is just a variation of normal that sometimes happens and is nothing to be feared, either by the birthing women or the midwives. That being said, stillbirth and neonatal death are also, sadly, commonplace in this setting. These women are among the highest risk pregnant populations in the world. Malnutrition, anemia, hypertension, high parity, and poor living conditions among other things, all contribute to the morbidity and mortality. Every woman that walks through the maternity door is high risk. A breech presenting baby is not really given a second thought.

Last week a young woman came to the maternity in active labor accompanied by a traditional birth attendant (TBA). This is the norm. The TBA’s are also from the Rohingya population and they worked as TBA’s in Myanmar before they fled the country in 2017. Here they are volunteers as they are not legally allowed to work. They are our link to the pregnant women in their communities in the camp; we rely on them to get women safely to the maternity.

I could see by the way this woman was walking that she was in active labor although her face betrayed nothing. With a series of hand gestures, I ushered them into the birthing room so I could do an assessment. Fortunately, the TBA knew the drill. We are seriously under staffed with several midwives out due to COVID and where there would usually be 5 or 6 midwives; there was 1, and me. This particular midwife had very limited English and I hadn’t been assigned an interpreter yet, so that day we communicate by me repeating things several ways until she understood what I wanted to know. Along with a lot of pointing and pantomime, eventually I would get my point across.

The TBA asked the woman to get on to the table so I could do an assessment. I was going to check for
dilation first because she seemed quite actively in labor but she was very stoic. As she raised her skirt to prepare for the exam, I saw a little foot peeking out. I immediately asked her to get off the table. This was difficult because neither she nor the TBA knew what I wanted her to do. Finally they understood although they were confused. Fortunately, the midwife who was working with me had seen some of the vertical breech videos I showed the staff just the week prior. She was intrigued. So she knew what my plan was and helped me prepare the mother for an upright birth. She explained all the different positions the mother could choose to be in and told her just to do what she wanted. The woman nodded.

I was able to learn this was her first baby. She was 18 years old. She had no health issues. A quick
assessment of fetal heart tones was reassuring. Then she had a contraction. She found standing was her position of choice and she held on to the baby resuscitation table in front of her. The second push revealed more of the foot up to the ankle and I could see a butt cheek. This was a complete breech presentation and what I call compound complete because two different parts presented together. The only way I knew she was having a contraction was when the baby started to descend. She was very quiet although the pushing efforts were great. I could not see her face as I was behind her. There was a TBA beside her giving her gentle encouragement but I have no idea what she was saying. The baby was emerging LST (left sacrum transverse) which is completely normal. After a big push, the entire leg came out and the baby was birthed to the hips. Now the baby was doing the splits and had started to rotate to the anterior, which is what we want. After another contraction the other leg came down and the baby was down to just past the umbilicus and had completely rotated to anterior, the perfect position. The cord was visible and looked good.

Each time a contraction began, the baby did a tummy crunch. This was my indication there was a
contraction since I could not tell from the mother. The baby was in great condition with excellent tone and color. I was pleased and unconcerned. At this point, everything was textbook. I was able to point out to the midwife how the baby was helping itself be born by doing the tummy crunches, she was just amazed. It was so much better than a video! Between contractions the baby seemed to rest being half out now. By this time, a few other TBA’s had gathered in the room behind me. Word had gotten out of my antics and they wanted to see.

By this time, 20 minutes had passed from when she first arrived. The baby did another tummy crunch and I knew there was a contraction. Even if I could have spoken her language, she did not need any direction at all. She completely gave herself over to what her body was doing. She needed no words. As she pushed, I could see chest cleavage, a very good sign and then one arm came down and then the other. At this time, the TBA was doing a butt lift on the mother, although it was not needed. I didn’t know how to tell her to stop. I did ask her to but of course she had no idea what I was saying. The baby was now born to the head and still had great tone. The perineum was ‘hollow’ which indicated to me the head was not flexed. I waited for a contraction and it remained like this. I was not concerned. I knew the head was not trapped, it was just not flexed and this could be easily remedied. On the next contraction I did a shoulder press. Nothing. But as I pressed, I could also feel the baby’s heartbeat, it was a good rate and this was reassuring. I moved next to the rock and roll technique, which was also not getting the job done. Keep in mind, I also could not communicate with the mother to ask her to push and I had no idea what anyone else was saying to her. The baby could no longer really help because the entire body was out. Still, there was time and I was not worried because we still had good color, tone and heart rate. I wanted it to stay that way.

The next maneuver I did was modified MSV (Mauriceau-Smellie-Viet). The baby’s neck was completely exposed so I knew the head would come with a little help with flexion. This maneuver consists of sliding my fingers up the baby’s back to the nap of the neck and with my middle finger (the longest) I apply pressure which helps flex the head forward. Simultaneously with my other hand, I slide my pointer finger under the perineum to the baby’s chin and up to the mouth. I put my finger in the mouth. Usually when the baby is in good condition, it actually starts to suck on my finger. This baby clamped down and started sucking! As I applied pressure on the nape of the neck, I gently applied pressure down in the baby’s mouth slowly flexing the head. There is no pulling involved in this and it is done in a gentle fashion. I only needed to flex the head, it was not stuck.
As soon as the baby’s chin and mouth were present from under the perineum, I slid my finger out and applied a gentle shoulder press and the head released. The baby cried vigorously as I passed him
through his mother’s legs to her arms. He pinked up quickly, his heart rate and muscle tone were great and all of this earned him an Apgar of 10 at 1 minute.

In all, it was 25 minutes from the time the mother walked into the maternity to when the baby was out. The placenta came just as easily. The perineum was intact. Everyone was healthy. The baby weighed 2.73kg, which is about average weight for babies here. In retrospect, I think the baby’s head would have been flexed if the TBA had not done a butt lift at the time the baby’s shoulders were emerging. This is only a guess on my part but in my experience, when everything has been textbook; the head is usually flexed and comes out without maneuvers. This speaks volumes to keeping your hands off unless there is a true indication. I touched nothing through the entire process until I went to flex the head. Of course we will never know for sure if that little bit of good intention from the TBA interfered with the process, but I will not allow it to happen again.

After the birth when the mother and baby were resting in postpartum, with the midwife interpreting, I told her what a great job she did and had the midwife explain that babies don’t usually come out like that and she should be proud of herself. She allowed me to take a photograph of her with her son. Her family said they hoped Allah would bless me. I have attended a lot of breech births in my midwifery career, but I will always remember this breech in the Rohingya camp with this beautiful first time mother.

To learn more about breech birth, the terms and maneuvers used here, or to see photos and video of physiologic breech birth, please go to: https://www.breechwithoutborders.org/ They are a wonderful non-profit that does breech training, education and advocacy. They are a valuable resource on all things breech.

End of mission…sort of

My mission in Bolivia started on Jan. 22, 2020, and was to be for 3 months. Next week I hit the 3 month mark but there is no end in sight for the mission due to borders being closed and all flights in or out cancelled.

Bolivia is a beautiful country with equally beautiful people. I love the mission project, which is basically facilitating training of doctors and nurses in maternal/infant health protocols as Bolivia has the dubious distinction of being the Latin American country with the highest maternal and infant mortality rates. Our project works with 2 community clinics and does health promotion, psychological support for victims of sexual and domestic violence and maternal/infant health. We encourage women to birth in our facilities rather than at home because they lack any kind of skilled care at home and the outcomes are often poor. So we offer culturally sensitive care and respect the birthing practices and rituals of the indigenous population, mostly Aymaran people. They birth vertically if they so choose and are offered only warm food and drink, which is their tradition during labor and postpartum. Nothing cold can be consumed.

An Aymaran woman laboring with her mother as support.

For over 2 months I worked in the clinics and alongside the doctors – there are no recognized midwives in the Bolivian health care system so doctors attend all births in clinics and hospitals – and it was challenging and rewarding. Episiotomies are routine for first time mothers, a habit very difficult to break. There is however, not the routine obstetrical violence I have seen in clinics and hospitals in Africa, although I suspect this is only true in the facilities where I work because I have heard awful stories of hospital birth here. Still, I am glad to not have to be witness to that. The women who birth in our clinics are treated with kindness and respect.

COVID-19 has been hanging over the mission pretty much since I started. We all knew it was coming and as it got closer, we got more briefings and more information. Without knowing what the Bolivian government was going to do, all we could do was wait. When it was becoming obvious that borders would be closed and flights were likely to be stopped, we were given the choice to leave at that time since it was unknown when we would be able to go if we stayed. No one left.

MSF cannot make any moves or directives in the clinics we support without the full and express permission of the health ministry here in the country. These are not MSF clinics, they are Ministry of Health clinics that we provide support to. So one day we were all going about our lives and the next, everything was shut down, including borders, flights, all stores – everything. We were ordered to stay home 24/7 with exception being that from 8-noon M-F, based on the last digit of your ID, you could go out on your assigned day and shop for the week. No one under 18 allowed out at all – ever (I can’t tell you the last time I saw a child) and anyone out after noon or on a Saturday or Sunday is fined 1000bs for walking, 2000bs for driving and 8 hours in jail. Police and military patrol on foot and by vehicle and there are checkpoints everywhere.

The queue for the grocery store. Show your ID, get temperature taken, hands sanitized and bottoms of feet sprayed.

All of this might sound extreme but this is a country of 12 million people. We have 500 ventilators in the entire country. As of this date, April 14th, we have 354 cases and 28 deaths. Whatever we are doing is working so far.

I understand that most people do know what it is like to be a humanitarian aid worker. There is a limited understanding that ranges from “that sounds so exciting!” to “that sounds really awful!”. And the reality is, it is both of those and everything in between. We are away from our homes, families, friends and pets for huge amounts of time. We live communally with people we don’t know but get to know but staff is ever-changing. Some are people we’d gladly live with if given the option and others are people we would barely give time of day to under normal circumstances. The food can be limiting, weight is lost or gained depending on the context. There may or may not be reliable internet so communication back home can be hampered. Sometimes security is high and movements are limited. In certain contexts it is hot, like 100 degrees hot and there is no AC. Sometimes we live in great accommodations and sometimes it’s a tent! Sometimes we have the supplies we need at the clinic and sometimes we do not. And by supplies I mean, things that could mean life or death for a patient. And then there is the work itself. On any given day, one might see a child die of malaria, a baby die because labor was just too long, a woman die because her AIDS was just too far advanced for any medication anymore or an infant starving to death because his mother died and he has no will to live. This is the work. Heartbreaking, frustrating, sad but always challenging. It motivates us to help the next person. You cannot dwell too long in the “what ifs” because there is always someone else who needs help.

Aymaran women waiting for vaccinations for their babies

How we get through missions is completely up to us. We have the support of each other, the other team members, we have our individual coping mechanisms (or lack thereof for some of us!), we have psychosocial support from HQ and we have people back home who love and support us and this is a huge help on mission – the connection back home.

This mission has been a dream. There are 6 expats including myself. We have hot running water, live in nice apartments and have no security restrictions. And then COVID-19 arrived. While all the restrictions are limited, we are able to go to the clinics on special movements at special times because we were granted permission by the ministry of health and are essential workers. So although our hours are limited, we continue to work. This was all manageable, even the huge amounts of time spent in the apartment longing to be outside where the weather has been gorgeous now that the rainy season is coming to an end. All manageable except that as the rest of the world is falling apart, those of us out here working far from home are all but forgotten. So when the tough stuff comes, abandoned newborn on the clinic doorstep, stillborn baby to first time mom, a 14 year old sexual violence victim, a baby with a cleft palate born to a single mother – oh yes, in the midst of COVID-19, life still happens and it is that much tougher due to the pandemic.

The frenzy of panic and self-absorption as seen from a distance by those of us who regularly work in a context of emergency or even semi-urgent, is quite striking. The whining over restrictions, the hoarding of toilet paper, indignation over not being able to go from home to cottage or not being able to purchase home improvement supplies because they are not an essential item and WHY are they not? – very eye-opening. This first-world entitled attitude that has always existed in the U.S. has been magnified by this pandemic. It is shameful to me. I am embarrassed by it. Watching the flagrant disregard of stay-at-home orders is very frustrating. All I can think when I see that is, the longer you all disregard this and think the rules don’t apply to you, the longer we are ALL stuck! This is so much more than about you!

There seems to be an inability of people to grasp the fact that, although we are all in this together, we are all having very different experiences. Same storm, different boat. There is a difference between someone being restricted from going to their cottage and someone who was living paycheck to paycheck and now doesn’t have enough to feed their family! I have friends and family in both positions. We probably ALL do! I know there are a lot of people a lot worse off than me and I am here working helping some of them. It helps to get outside myself. Didn’t we learn at some point in childhood to put ourselves in someone else’s shoes? When did we lose this lesson?

I have learned to focus on the people out there helping, being funny, being creative, finding ways to survive the stay-at-home orders and helping others. Friends in dog rescue, still rescuing dogs! I have a small handful of friends who have checked on me and for them, I am truly grateful. I cannot tell you how isolated I feel. Unlike most people, I am not quarantined at home, I am far from home. I have no friends or family here. This is not my country. This is not my language. This is not home. For me, the 24 hour a day order to be inside is manageable, especially since I can work a shift once a week and work from home on my computer. But there are still times when I get desperately lonely and feel very isolated and most of that is because of all the unknowns.

A normal mission might be 6 or 9 months but there is always, always an end date. My mission was 3 months and it was to end the 22nd of April – next week. I knew weeks ago this was not going to happen and I made a certain peace with it. But still, it hangs there, this unknown date which, once it does come, might come quickly, as in, “we got you a flight out tomorrow!”. There are no ‘goodbyes’ to staff or the people one has worked with for months, I just go. The uncertainty of what lies ahead at home – where will I go in a country that is in quarantine? No one wants a traveler on their doorstep.

Then sometimes fear creeps in. Waiting to learn a close friend or family member is critically ill. It could happen. It happened on my last mission. This time, there is no way home. Conversely, if I were to become critically ill on mission, normally I would be on a Medivac out and repatriated. This would not happen now, there is no way home. I make peace with those things on a daily basis. It is a process. These are my realities. This is my boat.

So here I am in Bolivia. I will continue to help the mothers and babies as long as I am here and in between I will hope the rest of the world finds a way to make peace with their circumstances. I see friends doing it on social media. There is despair, ranting, a grieving of things and events that have been lost, but then there is hope. There is working through the loss, because there has been loss – a LOT of loss and grief. Grief is good and healthy. Those are the posts that get me through. So be frustrated, be sad, grieve and then get out there and do something! Enjoy the small freedoms. Enjoy your yard in the springtime. Watch the birds. Help an elderly neighbor, foster a dog or cat, play a boardgame with your spouse, children or roommate, take an online class – the possibilities are endless, especially if you have a yard and can go outside! People are literally risking their lives on the frontlines every day while a large portion of the population is being asked simply to stay home. Although I know it is not simple. None of this is simple. Not for you, not for me. So be kind to each other. Ask for help if you need it. Cry if you have to. Be grateful for the small things. Soon the storm will pass. Let us be able to look back on it and say we were our best selves.

Mairy Unchained

I have encountered many things in my life and in my humanitarian and midwifery career and I am prepared for just about anything because I have learned that I have to be. A lot of it is not easy. Much of it stays with me. Some of it goes down on paper, like this story.

We were called by one of the PHUs about 2 hours away and told of a woman who had had a baby 4 months prior and was at the PHU and was very combative and agitated and they were having to tie her down as she was being violent. They asked us about evaluating her for post-partum psychosis. They understood from family that she had experienced similar episodes to this one after her last birth. I told them I would not be in that PHU for a few days but that I could go and see her when I came at that time. I wasn’t sure what I would be able to do for her but I could assess the situation and make sure her baby was okay and being fed and not in any danger, but without a proper psychiatric evaluation and proper medications, I would not be able to do much. Sierra Leone has one psychiatrist in the entire country and he is in the capitol.

When I arrived in the village, I was taken by one of our outreach nurses to the place where the woman was staying. She was no longer in her own home due to her condition. When we arrived, we were escorted through the dark mud hut and to the backyard where there were a number of people, family members I would guess, several children and a myriad of chickens pecking around – the standard African village scene.

It was there that I first saw Mairy. She was seated on a wooden bench. She looked tired, sad, frail and dejected all at once. She barely looked up when we greeted her. The outreach nurse explained why we were there. I knew that the staff at the PHU had not known how to handle her and in fact that she was not treated very well because psychiatric illnesses were not very well understood here. I knew I would have to try a better strategy than they did in order to figure out what was going on with her. So I sat down next to her on the bench and I asked her how she was doing. The outreach nurse interpreted for me. It was at about that time that I noticed she had one ankle shackled and the shackles were padlocked and nailed to a board.

I have witnessed a lot of things during my times in developing countries – newborns discarded in the bush in black plastic bags along with their placentas, small children dying from cerebral malaria, children with untreated hydrocephalus, woman after woman with type III female genital mutilation, 11 year olds giving birth, women coming into to be surgically repaired after their wedding night – you get the gist – but I have never in my life seen someone shackled for a psychiatric illness in their own backyard. I cannot begin to explain the myriad of emotions that washed over me at the time. I kept my composure and continued to talk to Mairy through the outreach nurse. He explained to me that sometimes she was making sense and sometimes not. I could tell by her rambling responses, even though they were in Mende, that she was confused and not always making sense but she was not at all agitated.

After speaking to her and her father and mother who were also present, I gathered Mairy had had several violent outbursts. She threatened people, was combative and generally out of control. So they shackled her for her own protection and that of others. There really was no other option in their minds.

I learned that Mairy had given birth 8 times. She had 5 living children and 3 that died from fevers, probably malaria – people here generally don’t know cause of death many times. After the birth of her 7th baby, she had a similar episode to this one. The recent birth, 4 months ago, was normal and all was well until a few weeks ago when she had these episodes of violent outbursts.

I told Mairy and her family that I could assist with family planning. I explained that regardless of the cause of her illness, that her high parity put her at risk for maternal death. Also, if her illness was indeed related to pregnancy, family planning would be the best option at this point as well. Mairy’s 5 children were being cared for by her family. Her aunt was caring for the baby and bringing the baby to Mairy for supervised breastfeeding. So Mairy was not able to mother her children at the moment, which further made the case for family planning.

I suggested implants as the best option because they last 5 years. Mairy and her family agreed. We agreed I would come back the following week (the PHU is 2 hours away, one way) and we would put in the implants.

I asked about Mairy’s baby. I wanted to see him and more importantly, I wanted to see her interact with him. The aunt came out with the baby and handed him to Mairy. It was clear he wanted to nurse, so she fed him. I asked his name. Emmanuel. The outreach nurse asked if she knew any songs and if she sang to him. She smiled and replied that she did. Then she began to sing a hymn from church. While she was loving an appropriate with her baby, it seemed to me that she was also doing what was expected of her at the time.

Mairy continued to talk through the outreach nurse. She was explaining something to him and was quite emphatic. He was talking and gesturing towards me and laughing. I asked what they were saying. Mairy explained that because the belief was that there was something ‘wrong with her head’, all of her hair had been shaved off in an effort to cure her. She was very angry about this and felt she was ugly. Her head was wrapped, as most women do here so I did not know her head was shaved. The outreach nurse said he told her, “It is okay, look at Kristine, her head is shaved too!”. I laughed when he told me this and then I turned to her and she took off her scarf revealing a beautifully shaved head. I said, “Look at you! You are beautiful! You are just like me!” She smiled and then we laughed together. I knew then that I had gotten her trust and we would be able to help her.

We made a plan to check in the following week and do the implant for family planning. I informed them that I would also check with the MD for any medication we could give that would help but also not interfere with breastfeeding. Everyone agreed to this plan and Mairy was willing to try medication. My goal was to get her off the chains as soon as possible.

Back at the office, I immediately consulted with the MD and the medical coordinator for the project. Both agreed a low dose of Haloperidol would be the most appropriate thing to give her first. By the following week we had ordered it – a special order had to be placed because we don’t have most medicines on hand, particularly not psychiatric medications.

We went back to do the family planning and Mairy came to the clinic with her baby. She looked good, happy even. She greeted me with a smile. The outreach nurse placed the implants. When Mairy went to leave, she took my hands and she thanked me in Mende. I could see she understood I was trying to help her and she was grateful. I was grateful she seemed better.

The following week Haloperidol was given and Mairy improved. The next time I saw her she was at her own home and no longer shackled. She greeted me with a big smile and her baby on her back. She looked radiant and her baby looked fat and healthy.

Arrival in the village of Punduru – a 3 hours motorcycle ride one way.

Mental illness is a health crisis in Sierra Leone. There is so little understanding about it and it is clearly stigmatized. There is also so much superstition surrounding it. Cursed by devils, married a witch, swallowed an evil snake and so on. People who do seek care generally go to traditional healers. There the evil is cast out, heads are shaved, like in Mairy’s case, herbal medicines are given, spells are cast.

Mairy continues to improve and we are hoping she is through the worst of her illness. She reports feeling much better. We will continue to support and monitor her over the coming months. If indeed her illness is postpartum related, then she should recover completely and this is what we are expecting.

An Average Day

A large part of my job is supporting the 10 peripheral health units (PHU’s) in the 2 chiefdoms we cover for this project. One of them is right next to the office here in Baama. The remaining 9 vary between 15 minutes and almost 2 hours away depending on whether you are in a vehicle or on a motorbike. During the rainy season, the furthest one can be over 3 hours away because we take a different route and can no longer cross the river at the easy access point.

Adjusting backpack for proper balance and stability. Knee pads and elbow pads, just in case. Instructions to my rider from logistician, “don’t break the midwife!”

I usually set my activities for a week at a time and visit the 9 PHU’s on a rotating basis but the most that could be visited on a given day is 2 given distance and even then I cannot spend much quality time given the time restraints we have for our working hours. So at the end of the week I choose 3 days to be in the field the following week, working around meetings and other things on my agenda. I set my locations and file a movement plan with logistics. They then make a schedule with all the movement plans and either assign me to a vehicle with the outreach department going to that PHU or they assign me a motorbike and a rider if no one else is going that direction. It is all carefully planned.

Being the only midwife on staff, I am busy fielding all the calls from the PHU’s when they have complicated cases or if they need to refer. The staff in the PHU’s are not trained as midwives, rather they have health aides and nurses staffing the PHU’s due to shortages of midwives here. So while the staff do all antenatal care and conduct the births, they are doing midwife duties but are not considered midwives by Sierra Leone Ministry of Health because they are not trained as such.

The PHU’s are extremely basic in the care they can provide. They have protocols to follow and are supposed to refer anything higher risk to a higher level of care, which is here in Baama where there is the one trained midwife for both chiefdoms. Even here in Baama, “higher level of care” does not mean much. The nearest hospital is 3 to 4 hours away on a good day in good weather and requires our ambulance to meet a national ambulance at the ‘kiss’ point across the river. It is a whole production and not a fast one.

This past Wednesday, I planned to go to Ngeigboiya (pronounced ge-boy-ya). It is far and the road is treacherous to say the least. We went by motorbike and believe me when I tell you I was not a passive passenger. There are some very steep and rocky points. The entire way is gravel – there are no paved roads out here. We have to cross tiny foot bridges not really made for vehicles so their stability is always in question. But the landscape is spectacular and it is like going onto a movie set as we pass small villages and young children wave and shout.

Prior to my departure that day, I was informed about a women who had died the day prior leaving behind 4 month old twins. The outreach department asked that I check on them and find out what they needed and how they were being fed. All babies here are breastfed, there is no other option. So there is always a concern when a mother dies as to how the baby will survive. I said that I would check on these two as they were in a village just 4 miles from the clinic.

When I arrived in the village, we were escorted to the house where the babies were. Both were very small for 4 months and clearly lagging behind in developmental milestones. I figured they were probably premature when they were born but I would have no way of knowing any history on them now with the mother dead. I learned that the father too, had died no long before. There were 2 other children, 2 and 4. All were now orphans. The mother died from complications of malaria. The 2 year old was currently hospitalized for complicated malaria but appeared to be getting better.

The caregiver explained that for the last day, the babies had been getting biscuits soaked in water and then boiled. The biscuits had run out and they were now hungry. There was no one in the village willing to nurse the babies because it is a commonly held belief that if you nurse the baby of another woman that your own baby would die. These beliefs are so strongly held, there would be no convincing them otherwise and I did not even try.

The village we were in does not have a well, therefore, when it is outside the rainy season, it is difficult for them to get water, let alone clean water. They fetch water from streams and wherever they can find it. There is no market in this village and they have to walk long distances for food as well, hence when the biscuits ran out, that was it.

I was able to put in an emergency order for formula when I got back to the office that day. It was really going to be the only thing giving these two a chance at survival. The next day a health promoter went with a rider to the village and brought the formula. They taught the caregiver how to prepare it properly. Most people in the villages are illiterate and they would not be able to follow instructions on the can so we always send a health promoter to give instructions. In the coming week, I plan to check on them again.

View of part of the village of Ngeigboiya from the clinic. The large building is the school.

With both parents being dead, the survival rate for these babies is not good. I do not know enough about the village structure and what sort of support the extended family will have to be able to care for these 4 children. They are all at risk. We will be following them and do what we can within our scope but it will not be an easy road for them.

Days here are full of unforeseen challenges. The work is not easy. I expect the coming months will bring with them a myriad of things I could not have imagined I would encounter. For now, taking it a day at a time.

A Lesson in Compassion

The week started off pleasant enough. I had a plan, subject to change at a moments notice based on emergencies, weather or various other factors. You always need to be flexible and adaptable in an environment like this.

I generally do not ride in the ambulance when there is a patient transport but we were called to pick up someone critically ill from a home (very unusual) and since she was not coming from a health facility, no staff would be there to go with her. I should say that our ambulance is equipt with a driver and very basic medical equipment, no one staffs the back of the ambulance because staff from whatever facility calls will go with the patient. The ambulance is basically for rapid transport and not care enroute.

I remembered the patient from the first day I started work. She had been referred to the maternity here in Baama because she was in labor but needed isolation due to co-infections of TB and HIV. When I met her, she was very thin, coughing a lot and in early labor. The midwife would care for her, administer the requisite medications and assist her delivery and she would be discharged a few days later with her baby boy.

When I received the call about the patient who was 4 weeks post partum needing transport to the hospital because she was in declining health, I knew who it was straightaway based on the village location and her description. Her baby had died, they said, and she had a worsening cough. Her family had tried traditional healers to help her but it was not working.

The ride in the ambulance alone was an experience. The breakneck speed at which the driver took the perilous gravel path was rather impressive and although no goats or chickens were harmed as we passed through villages, I did fear for a few here and there.

Once at the pick-up location (1.5 hours later!), we needed to find the patient. We were given a general area. There are no street names or addresses or anything else identifiable. We were told the husband would be looking out for us. So we parked in the middle of the village and waited in the swealtering heat; not difficult to miss since there are literally no other vehicles around, let alone an ambulance.

Finally someone comes to take us to the patient. When we arrive, I walk up to the porch where she is sitting, drinking tea and eat a piece of tapalapa (French bread). She was far thinner than she had been a month prior, in fact, she was skeletal. She had open sores all over her mouth and lips, candida inside her mouth and a horrible cough. When I looked at her all I could think was, this poor woman has end stage AIDS. I knelt down beside her and asked if she could walk. She said she could, so we got her into the ambulance. A large crowd had gathered in a matter of minutes, so I wanted to get her out of stare of onlookers. I took her blood pressure, pulse and temperature. Low BP, high pulse rate and high fever. I started an IV with antibiotics, although I knew it would not help. Her tiny, fragile body lay on the cot and she closed her eyes as we began the ride to the hospital 40 minutes away.

As we rode in the back of the hot ambulance, windows open to catch what little breeze we could, I looked at her lying there and wished I could do something. I saw how scared she was. I wished I didn’t need gloves and a mask. I wanted her to see my face, my expressions. I could not speak her language so this non-verbal communication was important but personal protective gear is also important. I wanted her to know in this moment, she was cared for. I got the feeling she hadn’t gotten much compassion in recent times.

As we drove, she kept spitting up blood tinged mucus and I knew aside from TB and without a chest X-ray, she had pneumocystis carinii penumonia and that it would eventually kill her, as it was a common killer of AIDS patients. I was so sad for her. At various times during the ride she would open her eyes very wide and get a wild, almost primal look about her – a look that begged the questions, what was happening? What was going in in her body? It is a far-away look, almost like she was glimpsing the other side. I have been with other dying people and I recognized this look.

The ambulance was loud and I hum to self-sooth as the ride continues. I put a gloved hand on her bony leg, her legs were the size of my arms – and I kept singing under my breath. A one point she put her hand on my knee and she looked at me. I could feel her fever through my scrubs. I smiled through my mask and nodded and said it would be okay. I kept singing softly because in that moment it was the only language we both understood. She finally closed her eyes. She kept her hand on me the duration of the ride.

When we arrived at the hospital and I did the hand-off to the doctor, she agreed with my assessment that the patient was in shock and had PCP. They were very busy so I wasn’t able to ask all I wanted like if they would make her comfortable and if she would be treated well. I knew she was going into isolation because I had requested it but that was all I knew.

I went back in to see her a last time and say ‘goodbye’. She grabbed me. She was frightened and did not want me to leave. In truth, I did not want to leave her. I told her it would be okay and they would care for her here. As I walked away, I hoped to myself that the latter was true. I knew I would never see her again. I knew she would die soon and I prayed death would be swift and as peaceful as possible. But I lived through the 80’s and I knew that, particularly in this environment, her death was not likely to be an easy one.

The ambulance driver and I rode silently home the entire 1.5 hours over the same perilous, rocky terrain that got us there. My day was only half done and I had no idea how I was going to find the energy to finish the second half. But after a cold shower and a change of clothes, I got back to it.

A few days ago I was informed she had died. She left behind a husband and 3 children. She was 30 years old. Although I could not do anything medically to help her, I hoped the 40 minutes we spent together in the back of the ambulance was some comfort to her, it was all I had to give.

Maternal Mortality

Sub-Saharan Africa has the dubious distinction of having the highest maternal mortality rates in world. The rates vary from country to country but time and again it is Sierra Leone that comes out as the worst, by far out of all of them and is in fact, the worst place to give birth in the world.

I am continually asked why women die at alarming rates in places like this. There are multiple factors that impact maternal mortality, not the least of which is access to care. I am going to specifically address this issue because it is one of the reasons MSF is here in these 2 chiefdoms; they are very remote and easy access to secondary care is lacking.

One of my tasks here is to do an investigation into any maternal deaths that occur in these 2 chiefdoms. The purpose is to figure out what the circumstance surrounding the death were, including location, weather, transportation, health of mother, preexisting conditions – everything. I go out into the field and interview the staff at the clinic where the death occurred, to the village where the woman was from and sometimes to a secondary clinic or hospital if the situation warrants. Then I write up an internal report.

Last week, a death occurred in an area about 2 hours from where my office is but within the district I investigate. The Ministry of Health also does an investigation and because we are here supporting them, we go out together for efficiency sake.

The document the MoH has is approximately 9 pages long. So I sit through a long list of questions for the birth attendant on the circumstances surrounding the death. If something is not clear, I ask for clarification. The MoH staff asking the questions are not medical trained to any great extent and they do not have clinical experience as a midwife or doctor, so their knowledge is limited to a degree.

The case on this particular day was a woman who had left her village via motorcycle after starting to bleed at home. She had complained to her family that she was tired, there had been a ceremonial dance the night prior and they danced well into the night and had cooked all day for the festivities as well. She went to lie down around noon and about 4 the family checked on her. She complained of abdominal pain but not labor and TBA was called.

Traditional Birth Attendants are often called as a first line because they live in the village and there are usually at least a few in each village. They are unskilled and the Ministry of Health has made homebirth illegal, so they are not allowed to practice. What they do do is bring women from the village into the clinics and stay with them, playing basically a doula role. I will write more about TBA’s in a future blog.

Time was taken looking for a motorcycle that could transport the patient. There are no cars here out in the remote areas of the country because the roads are too bad and so Okada’s are a large part of public transportation for everyone. They are specifically licensed motorcycle drivers for public transportation. Often 3 or more people will be on one small motorcycle, including small children and babies. They aren’t always available and in smaller villages, there may not be many depending on the time of day. In this case, it was over an hour before an Okada was found and by that time the patient had started to bleed. She was 36 weeks pregnant.

By the time she arrived at the clinic, which was 3 miles away, she had completely soaked a lappa (2 yards of fabric) with blood. Keep in mind, she was on a motorcycle on very bad roads so 3 miles here takes some time, one cannot travel at breakneck speed. She was pale, needed help walking and was very confused and disoriented on arrival according to the clinic attendant.

An IV with fluids was placed and the attendant called the ONE practicing midwife of the 2 chiefdoms as her protocol dictated. There are 2 midwives but only one practicing clinically – I am the other. I should say, by 2 chiefdoms I am talking about dozens and dozens of villages and over 65,000 people. The 10 PHU’s do not staff with midwives, they are just trained staff with basic skills. Anything out of their scope they refer, or they are supposed to refer. The midwife called advised another IV be started and a transport be arranged. IV was done and an ambulance was dispatched. Due to the distance of this clinic, the ambulance takes about 1 1/2 hours. This is normal and they cannot drive quickly on these roads but this was still better time than I make when I go to this clinic. The Land Rovers and can withstand the horrible terrain, make it up steep hills, get through mud, over rocks and through the river waters.

The ambulance arrives and loads and goes. It took 3 minutes. By the time they were 10 minutes away, the patient had died. Her cause of death was antepartum hemorrhage probably due to an placental abruption. She was 30 years old and left behind 4 children and a husband.

In this case, the sheer remoteness was a direct factor in the death of this woman. Nothing more could have been done for her at the clinic and even if the ambulance had been there in less time, it is still very likely she would have died given the high level of care she would have needed due to her critical state. She had already lost a life-threatening amount of blood prior to her arrival at the clinic.

So when people ask me why women die here at alarming rates, understanding the terrain and remoteness as one huge factor is very integral to understanding how they factor into big picture.

While I could have gone into more clinical detail, which is information I have due to having done the death investigation, I felt it important just to lay out the basic facts and keep as much private as possible, including actual locations and names of places and people involved. I am happy to share specific clinical information privately for any midwives or clinician out there that want more specifics, just message me.

I will be addressing other causes of maternal death in later postings. I am here 8 more months so there will be plenty of time. Suffice to say, in Sierra Leone, giving birth is the most dangerous thing a woman can do.

Team Life: The Untold Story

I am always the first one up in the morning, but I generally like early mornings because they are calm and peaceful and I have time to be alone with myself and drink my coffee, enjoy the sunrise and think. I have always been like this. How I survived a childhood waking up to 6 loud siblings I will never know, but now I know it was a small victory on my part given my true nature.

Now that I have painted an idylic picture of my morning and even given you an actual picture of the view from our compound, let me describe the scene in a more real way. First, there are birds chirping all around in the jungle surrounding us, and were it not for the generator noise, I would actually be able to hear them!

Sitting at the table enjoying my coffee, little tiny ants start to crawl on me because they have come overnight to look for bits of crumbs we left behind from dinner, but who can blame them? The security guards make constant rounds checking for intruders – not really of human variety, but more snakes, scorpions, giant spiders and anything else that might put us in peril.

Beside the compound there is a trail that leads up to the jungle where there is a ‘spring’ of sorts. I hesitate to call it a spring but let’s do that for the sake of simplicity. The fence around the compund is made of tall bamboo standing next to each other. So it is possible for people to sort of see in at just the right angle. At any rate, we can hear the villagers passing by with their buckets heading to the spring. It is generally children. This morning, one boy was using his bucket as a drum as he passed by to fetch water. On the upside, it drowned out the generator for a minute! Drumming is far preferable to the “hello! hello! hello!” we constantly hear during lunch or whenever we are sitting at the table during the day, as they peer through the slats. We can’t respond back because once we do it would never end!

At this moment, it is a balmy 23 celsius (75ish) and perfectly comfortable. By the time I finish this, it will have gone up at least by 10 and I will be a sweaty mess for the remainder of the day. There is no sleeping in because it gets clausterphobic after about 9am, although some people in the house manage to sleep past 10a on weekends and I admire them. They likely had more alcohol in their system than I did when they went to bed. We are all usually up by 7:30 for work at 8 during the week. If we want to do anything fun on the weekend, like hike in the jungle or go down to the river, we have to do it early in day or later in the afternoon because mid-day is just a recipe for sunstroke. None of us can do it. The sun goes down around 6:30 or 7 every night, so we can’t stay out late.

At some point, the sun gets high enough in the sky to use the solar and they can turn the generator off. When we have movie night and project from laptop to the sheet on the wall, we have to use subtitles, not because of any language barriers but because we can usually barely hear the dialogue over the hum of the generator. So basically when we want to enjoy ourselves and relax on the veranda, early morning and in the evening, we have to compete with the generator.

When I first arrived, we were flushing the toilets with buckets of water, which is pretty normal for this kind of environment. But at some point, someone decided we needed an upgrade and the handyman made it so the flushing mechanism would work on the toilets. I would say we each got a flush or two in before both of them had broken handles. The handles are just not sturdy enough and you can feel it as soon as you use it. So we are back to bucket flushing, which for me, isn’t an issue. We have more pressing things to be concerned about.

Then there is the neverending saga of my room; the love-hate relationship, shall we say, that I have with it and its contents. My room is small, which is fine but it is the smallest, by far of all the rooms in this house and in city house. To give you perspective, all the rooms have a full sized bed, armoire, bedside table (some have one on each side!) and a desk. And even with all of these things, there is still plenty of room to say, do yoga or something. Mine, not so much. I can only dream of a desk. Even if there was one available, it would not fit. Still fine though! When I arrived, I had no bedside table, a mosquito net with holes and no hangers. Okay, all fixable with time. It took about 5 days to get a new net. Here, you can’t just go pull one off of the supply shelf, everything is inventoried. You need to fill out a request form, submit, they process, they get the net, air out and then you come home from work one day and magically it is there! Wonderful. On to the bedside table. Same deal only without the airing out. The only caveat is, if there isn’t an actual unused bedside table, the carpenter has to make one! (no Ikea or Wayfair here). But this crew was sympathetic to my plight and someone brought me a wooden chair from the other house to use as a table. Fine. I’m happy.

And then the day the white dust started to appear all over my things inside the armoire. I won’t leave you in suspense – termites. So I inform supply, again they ask me to fill out a request form. I pack all my things up because I know they need to take the armoire. A few days go by and finally I see the armoire in the backyard being taken apart and treated, I know the end is near. It is getting tiresome living out of my backpack continually digging around to find what I need, I just want to unpack.

I finally get my armoire back after several days. I can be happy. Room, chair/bedside table, armoire and I even scored a few hangers. Ahh. I go to open the armoire and it almost topples over on me! WTH? I stablize it. Look at it. It is squarely on the ground, doesn’t rock when the doors are closed but when you try to open it, yikes! And it’s big! So reluctantly I call the supply guy, who conveniently lives in the room across the hall. I ask him to check it out. We determine that the handyman took the wooden back panel off the armoire and replaced it with a light pressed board. The laws of physics did not appreciate this. As a temporary solution, we got some rocks and pushed them under the front of the armoire to keep it from toppeling over – desperate times… It was going into a long weekend and nothing would be fixed anytime soon. Fine. I’m flexible, this is West Africa.

So the cleaner cleans our rooms every day. When she does, she sweeps and mops. Delightful! – except if you have little rocks stablizing your armoire that get dislodged by her mop every. single. day.

DANGER!

As I write, the rocks are still there. Every day I come home and have to remember to check for them and make sure they are placed correctly before I open the armoire. At night, I lie in bed and have visions of the entire thing coming down on me in my sleep. I informed supply guy that if this happens, under no circumstance should this be put on my death report! I won’t be taken out in the jungles of Africa by an armoire! Black Mamba, hemorrhagic fever, hippo attack – anything but death by armoire! Nervously he agrees.

That same day, as I am changing after my shower, I have the door of my tiny hot room closed. I notice the armoire has a new laquer finish and that whatever toxic substance they coated it with, smells to high heaven. My entire room is filled with the fumes. I blast my fan, I open my door, I make sure the widow is wide open and I retreat outside, hoping it is fume free enough by bedtime so that I can sleep.

Speaking of sleep, my room is situated in the front corner of the house. The windows are feet from the guard stand. They are there 24/7. They are not allowed to sleep at night, so guess what they do? Yes, music and videos and other things on their phones. It is quite a delight. The trucks, 3 of them, are also parked right there, along with at least 2 motorcycles. So if there is a rare movement in the night, they will fire up the Land Rover and there is no sleeping through that. Then even if they are quiet, there is always the random baby goat making noise, or child crying in the distance. Yes, I could close the window but then I am in a hot, clausterphobic, fume filled, temite infested danger box and who will hear me scream when the armoire comes down? Anyway, even with the windows closed, there is still a lot to be heard, so it isn’t worth it to not have the air.

One day last week, I came home to find a fine white powder on a pair of shoes I has tucked under my chair/bedside table. You got it! TERMITES! And the saga continues. I refuse to change rooms at this point because I will not be vanquished by a room and its contents! Plus, my room has a nice view of the sunrise and mountains in the distance and no other room has that, so I am holding on to the positives. I also know I could be somewhere more heinous next mission and it could make this room look like a palace! I imagine a day when I will be longing for the comfort of this room as I sleep in a hot tent, on a pad on the ground with a storage locker that won’t kill me, keeping my posessions safe.

The positive side is that I get to share my days with a small team of expats from all over the globe. They have all been here for varying degrees of time and will stay varying degrees. One person has already left after a year and his replacement will come in a week or 2. Another is leaving later this week. Currently, I will be the only one left of this team by the time I leave in late December. I will have a lot of ‘goodbyes’ before I say mine.

Sitting down for meals is like having a small UN meeting. I get to listen to everyone speaking my language with their unique versions of word prounciatons; it is a beautiful euphony of accents. And everyone is multilingual. Arabic, French, Portuguese, Norwegian, Spanish and various tribal languages learned over previous missions. It is rather impressive. So when someone new comes, it is like opening a present. What new, fun, exciting thing do they bring to the table?

I expect to have a little time to write later this week about maternity care, as we have Wednesday off because it is a national holiday. Inshallah, as they say here, unless I am take out by my armoire.

One week in

It has been a week since my arrival in Baama and I am starting to settle in to both team life and work life. Fortunately, this isn’t an urgent emergency response type of mission so we work at the pace of the local people, which is slow and casual. It is hot, as I mentioned before, so there really is no other way to be.

I am getting a better understanding of my role here now that I have visited some of the clinics we are overseeing. The context and background for this project are as follows:

The maternal and under-5 mortality in Sierra Leone are ranked as the highest in the world. MSF has chosen to give extra attention to a very rural and neglected area in the east of the country where the infrastructure is poor. The health facilities are decayed and the roads are in general, rough roads where only 4 WD trucks and motorcycles have access.

Sierra Leone’s dubious distinction is not just its supposedly record-breaking rate of maternal death. A World Bank line graph plotting the World Health Organisation’s estimated maternal mortality rates for low-income countries over the past 25 years, shows war zones such as South Sudan and the Central African Republic closely bunched together. But Sierra Leone’s line, while decreasing gradually from a high during its own 1990’s war, is extraordinary. It floats high above the rest. This estimated ratio is almost three times higher than the average for sub-Saharan Africa. The statistics are a mark of continuing infamy for the country.

Gorama Mende and Wandor are two chiefdoms in Kenema district, the district where we are focused. The population in total is approximately 64 000 inhabitants residing in small towns (villages) spread around in the jungle forest. The most populated towns have Peripheral Health Units (PHU) to provide health care. These centers are all a part of the primary health care service and are served by staff from Ministry of Health and Sanitation (MOHS) and volunteers.

There are 10 PHU’s that I am responsible for visiting in order to gather data, consult on complicated cases, make referrals and ascertain what training the staff needs. I then coordinate the training and work with the outreach teams to accomplish the training goals. While this all sounds fairly simple, logistically it is extremely difficult because the PHUs are scattered over a large area with the aforementioned roads our only access. During the rainy season, the roads are worse and there are PHU’s that literally take 3 or more hours to reach after which time we can only stay about an hour or so before we have to return back to base! So 6 hours in a vehicle on horrible, bumpy roads and work for 1 hour. You see the challenge.

To give you a frame of reference, on Saturday we visited 3 of the PHU’s so I could be introduced and so we could check on some renovations that MSF had help facilitate. We were away for 6 hours total. We managed to visit all 3 PHU’s with short stops of about 15-20 minutes at each place. So less than 1 hour was spent outside the vehicle total. The urge to vomit was continuous and I managed to overcome it with the help of tic-tacs and mind-power!

The government here has made healthcare free for pregnant women and children under 5, in order that they might make a dent in their maternal/infant and child mortality and morbidity. It remains to be seen if free care will bring more people into the health centers and help lower those rates.

Homebirth has also been outlawed, bringing with it very steep (by Sierra Leone terms) fines to the mother, any attendant, the homeowner and the father. I do not yet know if these penalties are being carried out because as soon as you drive something underground, like homebirth, there is an air of secrecy surrounding it. We know they still happen because women come to clinics to register their babies. Whether anyone is actively reporting them, I doubt.

Although care is free in the PHU’s, the providers – who are very basically trained – do not have much themselves and so they often charge patients. These health units cannot manage critically ill women, and those must be referred to the nearest hospital (sometimes hours away) by ambulance. So it is very easy to see why the mortality rate is so incredibly high here. Poor infrastructure, poor nutrition, lack of access to care, delay in treatment in emergencies, under-skilled staff – it is the perfect storm.

We are heading into a holiday weekend. We are off Good Friday and the Monday following Easter, so it is 4 days off for us. I plan to do some hiking, cooking, bird watching and a lot of reading and relaxing.

First Impressions

I arrived in Freetown, Sierra Leone on Tuesday evening. I completed 2 days of briefings and then went on to the project post on Friday. That entailed a 7 hour drive into the bush, the last 2 hours being the worst road I had ever experienced in my life! It is difficult to impress me with anything like depravity, extreme weather, bad travel conditions, poor infrastructure, bugs, insects, rodents or reptiles, physical ailments/poor health etc., so when I say this road was bad, trust me that I am not exaggerating. I will be a frequent traveler on said road being that I will be going to health posts weekly, so there will be time to post photos but I fear they will not do it justice and I may need to post a video on Instagram for full effect.

Sierra Leone is beautiful. The people are beautiful and the scenery is stunning. The above photo is the Sewa River at dusk just before a thunderstorm. The rainy season hasn’t started in earnest yet but every few days we get a little rain here and there and sometimes it is quite impressive. Once the rainy season starts, it will last 6 months.

The village where we stay is called Baama. There are 8 total expats in 2 different houses about 5 minutes apart on foot. The house I stay in is called the farmhouse. The other house is called the city house. I suggested we call one the snake house and the other the scorpion house because we are always finding snakes and they are always finding scorpions.

The accommodations are basic but sufficient. We each have our own room. Mine has a full sized bed with mandatory mosquito net, armoire, mirror and a window. No bedside table so I am using a chair at the moment. Definitely not furnished by Wayfair. The room is small but I have a fan so I can sleep relatively comfortably at night. We have solar electricity but a generator for back-up.

We take bucket showers. There is cold running water in the kitchen sink and in another sink where we brush our teeth. The cleaner and her helper cook lunch and dinner for us during the week and also wash our clothes, do the dishes and clean the house. We are mostly outside on the porch when we are home; it is too hot to be inside our rooms and there is no common area indoors. We generally are in our rooms to sleep and change clothes. It is about 95 degree average here. High 70s at night.

The other expats are from all over. Tunisia, Brazil, Kazakhstan, Ghana, Nigeria, Kenya, Germany and Lebanon. They make up the team that is Logistics, Medical Coordinator, Program manager, outreach nurse, doctor and midwife.

The office is located straight down the road about a 5 minute drive. I have a desk space there and will work out of the office but will be visiting health posts during the week much of the time. More on that in a later post.

The people in the village could not be more lovely or welcoming. This is not a tourist country and this certainly is NOT a tourist town! I am sure the first foreigners some of them have seen was a few years ago when Ebola came calling. 60% of the population is Muslim and the rest are Christian. They live peacefully together and even inter-marry. They attend each others functions and celebrate Eid and Christmas together and are a shining example of how religions do not need to be at odds with each other.

The area we are in is largely supported by diamond mines. That is the main work of many of the people here. Southern and Eastern Sierra Leone are very rich in diamonds and control of the diamond mines was the cause of the 11 year armed conflict, which ended in 2002. The conflict was particularly long and violent because both the rebels and the government were funded by blood diamonds mined by slave labor.

English is the official language of Sierra Leone, meaning that it is used in legal documents, government, schools and media. Since this is a very poor country, much of the population remains uneducated and without education, people do not learn to speak English. Krio is widely spoken by most people. It is an English-based Creole language that I believe will be fairly easy to learn once I get into it. Aside from those, Limba, Kissi, Kono, Fula, Mandingo, Kuranko and Susu are spoken by different people in different areas of the country.

This week I begin my briefings and orientation in the project. I will be writing more about my experiences here both clinically, culturally and personally when I have the time. Open to suggestions about specific topics as well.

On My Way

So it begins. With my HR briefing in New York City completed and my mission specific briefing in Brussels over, I fly to Sierra Leone tomorrow at noon out of the Brussels airport.

My role for this next mission will be Midwife Supervisor and is for 9 months. What I have learned so far is that I will be visiting several different clinic sites each week to support the local Ministry of Health (MOH) staff. Doctors Without Borders (MSF) are not currently active in these clinics, that is to say, we provide support, guidance, trainings, supplies etc. so that they may become autonomous at some point in the next few years barring anything unforeseen, like war, disaster, or another Ebola outbreak. I will not play an active clinical role in this mission, which means I will not be on call, which makes me very happy! I love my sleep! This isn’t to say I will not do anything clinical. If I am called due to an emergency or short staffing, I will be on hand to pitch in and of course I will do bedside teaching when needed.

Sierra Leone is about the size of South Carolina. It is among the poorest countries in the world. The 11 year armed conflict ended in 2002 but Ebola hit in 2014 and it is estimated close to 4000 people in Sierra Leone died. The country is currently still recovering from that Ebola outbreak, which ended 3 years ago. It hit hard in the area where I will be so there is a serious deficiency in trained medical personnel. It is estimated they lost about 200 medical staff to Ebola.

Aside from that, Sierra Leone has the highest maternal and infant mortality in the world. Due to Ebola, a lot of people are still mistrustful of clinics and health centers so often they will not seek care when they need it.

Malaria and Lassa Fever (another hemorrhagic fever which presents like Ebola) are endemic to the area. I will be addressing both of those in later post when I have stories to share that will make the topics more interesting! In the meantime, I started my malaria prophylaxis yesterday and will continue through the 9 months and a couple weeks after my return. There is nothing to take to prevent Lassa Fever.

Other required (by my employer) vaccines were Rabies, meningitis, typhoid and booster of tetanus and Yellow Fever – all very real dangers in the environment in which I will be. There were several other vaccines needed but I had already had them so I am good to go.

We are allowed 20kg to bring on mission with us. I use a Osprey pack which is easily carried on my back. Very little of what I pack is actually clothing. It is in the 90’s in SL so the standard MSF t-shirt and some lightweight pants/scrubs are all that is needed in terms of clothes. The rest are creature comforts and necessities like coffee, travel French press, nice smelling handmade soap from a friend, a journal, photos for my room, coffee, gifts for the staff on arrival, binculars, my Birds of Africa South of the Sahara book, for my bird watching addiction (don’t think all my posts are going to be about maternal/infant health!), and coffee!

I don’t know what my time, internet or electricity access will be like yet so I am not sure how often I will be able to write. But stay tuned, I will write when I can. I also post photos on Instagram (honeymother64), in case you want to check them out. I will post what I can here. I have never blogged before, but feel free to ask questions or make comments. I will answer when I can. Next post from Sierra Leone, West Africa!