I wrote this in my journal this week:
A twenty-one year old woman had a c-section for twins. The first twin was breech and that was the apparent reason for the surgery, though the report didn’t say she was in labor at the time. This was very unclear at morning report. The matron asked why it was done. The midwife didn’t know. The chart said, “c-section for multiple gestation”.
The twins are here in the nursery, where I sit. They are together in a wooden cot––a girl and a boy. There is a heater attached underneath and the cot is warm. There is a piece of surgical tape on the rim of the box. On the tape is written “Orphans”. Their mother died after she was taken back to the operating room a few hours after they were born. Her abdomen had swelled and the residents thought she was bleeding internally. Apparently there was no bleeding but some fluid from her liver. The nurse at report said they thought she died from some liver disease, maybe hepatitis.
On the babies’ charts, in the section titled “Problems With The Mother”, all the circles were around the “No” column. She’d apparently had no prenatal problems and had gotten regular prenatal care. The twins are almost equal in size; she is 2200 grams and he is 2300 grams. A boy and girl, so they were most likely in separate sacs. I read a doctors note saying they were hungry and crying so he wrote a prescription that said, “Supplement with Lactogen Formula 16 ml every 2 hrs.” I assume that was written before their mother died. It won’t be a “supplement” now, will it?
So I fed them. She took ten milliliters and he took twenty. The pediatrician came to evaluate them. She didn’t know their mother had died. I asked her what would happen to them now? She said the family would have to discuss it. She said, “The mother was married, so hopefully the husband will come to pick them up. It’s up to the family.” She told me they usually keep orphans in the nursery for a week and hope someone comes to get them. She thought they were big enough to get twenty-four milliliters every three hours, so changed the orders that the last doctor wrote. I told her the girl only took ten, but she didn’t seem to care. She wrote the order and said, “Very sad.” and moved on to the next baby.
I spent this orientation week in the nursery. It’s an intensive care nursery. There is no other nursery; all babies without problems stay with their mother. It’s hot in the nursery. It’s a new wing of the maternity ward, named after someone who must have donated the money for it. It’s well-lit, and very clean. There are twelve warmers like we have at home, with oxygen tanks. There are approximately twenty eight babies in the twelve warmers. Many of them premature, some of them with congenital defects, some have recently had surgery for those, mostly spina bifida. In another section of the large room are thirty wooden boxes on legs with a piece of plexiglass on a hinge that rests over half the top of the box. On some of these, are lights treating babies for jaundice. The lights are in a wooden frame and rest on top of the plexiglass. It can easily be moved away to open the lid and get to the babies. Most of these boxes had two, unrelated, babies in them. Every three hours the mothers from the postnatal ward come and feed and care for their babies. They bring clean chithenjes to wrap them in. Very few wear diapers, they mostly have a small piece of cloth around their behinds which soaks through everything when they pee. The mothers then put another clean cloth around them and wrap them in a fresh chithenje. In the week I was there, no one came to change the twins. The midwives have a small stash of disposable diapers and they put one on each of the twins. They were probably a size for one year olds and they covered almost the whole body of these little four pound babies. But they absorbed a lot so only needed to be changed once a day.
Formula gets mixed up in the morning and sits out on the counter in a plastic pitcher. When someone needs it for one of the babies, they go pour it into one of the small cups and sit and and dribble it into the kids’ mouths. Most of the mothers, however, pump their breastmilk and feed it to their child in the cup. These are the babies that are too small to suck. Some are only two pounds. Many of these women have had c-sections for these tiny babies. It’s making me crazy.
For three days I fed the twins every three hours with a little cup of formula. I held them and watched them sleep. I wonder what will happen to them? They are perfect little beings who made facial expressions when they slept like someone just told them an amusing joke. Or they looked old and wise, appearing to be quietly listening to a story about their birth and how their mother always protected them from heaven. That was a little fantasy I had. That they’d have long, happy, productive lives and they’d feel blessed that they had this angel always looking out for them. I amused myself for awhile with these fantasies, but as the week went on and no one came to see them or bring them a clean chithenje, I asked the midwives what they thought would happen. They said, “Often no one comes to get them. Formula is expensive. Most families can’t afford to buy it. So sometimes they just feed the baby cows milk and they get sick and die. Sometimes they put the babies in the coffin with the mother because their chance of surviving is so small.” They shake their heads and say they don’t know why the mother needed the surgery. Mostly the midwives ignore me but they are polite when I ask them questions. They have no time for me. They seem glad I have something to do when I feed the twins. It takes some time to feed them with the cup. I can only give them a few drops at a time. I sat among the mothers who were holding their own babies and they smiled at me. They talked a lot among themselves and some spoke to me in English. They look at the twins and shake their heads.
On Thursday I went to the maternal mortality report at the medical school. I was interested to compare the reports of this particular death. The one I heard at the morning report the day she died was from the nurses. The residents presented the case, what transpired, and what they thought was the cause of death. There was quite a difference between the two reports but this could only be noticed by the nurses at both meetings. The medical residents don’t come to the nursing report. They said the cause of death was probably viral hepatitis. Someone asked if they’d taken a liver biopsy when they had her open. They said they did not. No one asked whether they thought the surgery was needed in the first place.
On Friday there were a lot of student nurses in the nursery and they fed the babies. I felt a little left out.
One of our group of volunteers is an OB/GYN from Vermont. She is stationed about three hours from here at a district hospital in Mangochi, but she’s in Blantyre for six weeks for orientation here. She is staying with George and me and knew how upset I was about this maternal death. She defended the residents’ decision because the first twin was breech. I argued that the woman wasn’t in labor and the babies were tiny. They could have turned. And why can’t they deliver a breech anyway? Why isn’t anyone teaching them that? “It’s just not done anymore” seems to be a viable excuse for condemning women to life-risking surgery. I just refuse to accept this. It’s like the worst of western medicine has been imported here.
I have one more week of orientation. This week will be in the postnatal ward and the postnatal clinic. I think I’ll go check on those babies every day, though.
On the home front, the gardener, Simon, has resurfaced. I’d felt guilty that I’d ruined his life by giving him the money for seeds. I asked Catherine (our guard) if she’d seen him. She said “Yes. Simon. He not serious.” And she made a drinking motion with her hand. I said, “I know. But I gave him money and I want to talk to him.” She found him at a neighbor’s house and dragged him out to the road to talk to me.
He greeted me, “Morning madam.”
I said, “Good morning Simon. I gave you money for seeds. Did you buy seeds?”
He said, “Yes, but I need 850 more kwacha.”
I laughed (in a scoffing sort of way), and said, “I will not give you more money. You have taken my money but I have no seeds. And you have not come back to make my garden. I will have to talk to your boss at the college of medicine. This makes me very sad.”
“Ah, no madam! I will be coming tomorrow to make your garden.”
“Ok, I will wait to see if you come tomorrow to make my garden.”
And as I was leaving to walk to the hospital, Catherine took my hand and said, “I walk with you.” So we held hands as we walked down the road and she said again, “Simon. He not serious.” I told her, “I will not give him more money. Don’t worry. I know he drinks. But he took my money so I want him to do the work.” She said, “Ah. Chabwino.” (Ok)
The next day I came home from the hospital to see flowers planted along the side of the house, lovely little beds made out back with seed packets on sticks marking what was planted where, and everything nicely watered. After a depressing day in the nursery, I felt much better. I told Simon I was very happy. George said, “Jesus, you are good. I would have given him the 850 more kwacha then felt like crap.”
Last night we had our first little dinner party to celebrate George’s birthday. George managed to get a case of beer (20 bottles) here on his bike. He had to take the seat off and tie it on the rack with bungie cords. It was impressive. I bought 4kg of pork shoulder at the “Lord Is My Shepard Pork Butchery” at our local market. The butcher hacked it off with a machete. I made that man very happy. I made a mole rub, wrapped it up tight with foil, and put it in the oven for as long as we had power. Having a dinner party is hard when you don’t know which hours you’ll have power! I managed to get most of the stuff made before the power went off at 3 p.m. We put candles around the house and finished things up on the propane burner on the kitchen floor. Our neighbor was bringing rice and he showed up early, saying he only needed ten more minutes of power to finish cooking it! Almost made it! I told him I could finish it on the propane, then asked if he remembered to bring the silverware I’d asked to borrow. He said, “Oh sure! Here.” Then reached in his sports coat inside pocket, as if he were taking out theater tickets, and handed me a bunch of knives, spoons, and forks. “It’s all I had.” he said. Someone else was bringing plates. I cut off the bottom of the empty tonic bottles to make cups for drinks, and we had a rollicking good time. Every bottle of wine that got emptied gave us another candle holder. Anneka made a delicious carrot cake on Friday so as not to have to bring over batter on Saturday if we didn’t have power. Polly made passion fruit ice cream and brought it in a knapsack on her bike. It was all warm and loving and fun. The power came on around 10 p.m., just as everyone was leaving.
The pork was fabulous. There is a little left over and I’m going to take some over to the butcher for him to taste. He told me he’d give me a very good price next time because he can tell I’m a good customer. I guess he doesn’t often sell 4kg all at once.
I think I’ll try the “Everyone’s Got Problems” goat butcher this week.