Surprises

Last week I spent one afternoon with Sakina, a very sweet and absolutely terrified 19-year-old who was pregnant with her first baby. She was having a difficult labor but refused all vaginal exams. After much time spent trying to calm her, she allowed me to check her cervix, first at 1pm (it was 9cm) and then again at 4:30 (it was still 9cm). Before I left around 6, I told the nurses and clinical officers about her and asked them to be gentle with her.

When I returned two days later I found out that she had refused a section early in the night, a vacuum had been performed at 3am, and then finally she consented to a section the following morning. Her baby boy was born around 6am but his journey into the world was too difficult for him to bear and he died just a few hours later. I was so upset. Yes, it is possible that she stubbornly refused the section after the best of counseling, and yes, the clinical officer who attempted the vacuum is a kind person. But, it was incredibly difficult for me to imagine that she allowed someone to do a vacuum (which in this setting involves inserting a metal cap that is 4-5cm in diameter into her vagina), considering it took several minutes just for her to allow me to touch her with two fingers. It was also difficult to imagine that she would refuse a section if she truly understood what was at stake, and believed that it was a necessity not a threat. Possible, yes, but difficult to imagine. I have seen women held down and threatened, and the vivid horrible memories flooded my mind. After visiting her in postnatal, seeing her silent tears, empty arms, and recent cut, I had a tearful conversation with Tarek about the situation. He listened, tried to help me see this one woman in the greater context of the Hospital and health care here, reminding me that things are improving but also saying that at present, the whole of Bottom Hospital is a human rights’ violation. That didn’t do much to lift my spirits and in the end he suggested that I talk about my observations during rounds on Wednesday morning.

Of course I forgot about my talk until 2am Tuesday night - the time when that internal calendar programs its adrenaline alarms - but I managed to put together some thoughts. In the morning I took my seat among the nursing matrons, the clinical officers and physicians (from day and night shifts, from the maternity units at both Central and Bottom Hospitals), and a handful of interns and clinical officer students. We went through the usual reports from the night shift and then just a few minutes before I spoke, a discussion started about particularly famous traditional birth attendant (TBA) in the area. Everyone seemed to know of her and several people said that even nurses choose to deliver with her rather than come to the hospital. Everyone was laughing, ridiculing a bit what they saw as the oddity of this woman and her following. Tarek in all seriousness suggested that we invite her to Bottom to learn from her, but everyone just laughed harder. The best story related about her was that when the TBA was confronted about some bad outcomes in her practice, her response was that she was extremely short-staffed and needed two nurses – in good humor one of the interns suggested I apply. (Why not? A weekend job? I’m sure I’d learn a lot – I’ll file that idea away.)

After everyone else finished I finally said my piece. I said a bit about how vaginal exams are routine for us (considering we probably do 100/day) but not for the women, how our goal should not only be health but good care, how women who refuse exams or seem “out of control” are not simply difficult but may have a history of sexual abuse, I made a plea to have patience and give care especially in the most frustrating and difficult situations, and I gave a few concrete examples of how we could change our practice. Especially after the discussion about the TBA, I expected silence and then disbursement of the group. But, the response was entirely different. Several people agreed with me quite emphatically and elegantly. A matron mentioned the TBA again – this time in a serious tone - suggesting that it was the TLC that brought women to the TBA and how the care, or lack there of, drove people from Bottom to her. The same male intern who teased me about the TBA said that the male clinicians should imagine themselves lying in the lithotomy position, giving birth at Bottom, and the sense of vulnerability they would feel. Someone else talked about how poverty was exploited, saying that women at Bottom aren't treated well because they are silent, they do not demand better, or even different, care. A few others also chimed in supporting what I had said. The reactions surpassed my most optomistic expectations. They gave me hope and lifted a weight that found its way to my shoulders long before I met Sakina. I am certain that this solves nothing but it is a beginning and demonstrates a receptivity that I did not know existed.