The Missing Middle

Tuesday I held a three-day-old baby while his grandmother, supported by the arms of strangers, watched as the maids loaded the body of her 17-year-old daughter into the ambulance. These things are not supposed to happen. I wasn’t in the labor ward when she died. I was in the theatre. When I came back Chipeta, the charge nurse, told me the story. The woman delivered with a traditional birth attendant on the 8th but was experiencing a lot of pain and bleeding and so on the 10th she went to the health center near her home. The health center transferred her to Kamuzu Central Hospital, (KCH has the only ICU in the Central Region of Malawi, but does not have a public maternity ward). Clinicians at KCH for some reason decided to send her to Bottom but as soon as she arrived, before she could even be assessed, she began gasping and then collapsed. The resuscitation attempt was unsuccessful. The clinicians speculated that she had an undiagnosed ruptured uterus, which lead to sepsis and eventually to her death. As she told me the story, Chipeta gestured to an older woman sitting on the bench at the entrance to the labor ward unsuccessfully trying to console a screaming baby.

Before the tears and the formula and hopeless gesture of stuffing a 500 kwacha note into the hand of the woman as she sat alone sobbing in the back of the ambulance with the still body of her young daughter. Hours before that, I sat in my car taking a in few breaths wondering what the day would bring contemplating the irony of how I was never excited to enter the hospital but how it was still the only thing I wanted to do.

The first woman I saw in the morning was in active labor with her fifth pregnancy. I examined her and found that the baby was in a breech position. The rest of her exam was normal. Because her most recent delivery was a c-section the decision was made to do another section. I went to theatre to receive the baby. After the first incisions, a blue and reddish mark appeared as a stain on the typically pearly surface of the uterus – a sign of imminent rupture. Then as the physician moved his gloved hand across the surface we realized that rupture was not imminent, it had already occurred. Part of the baby’s arm was visible through the tear. The baby was quickly removed and amazingly she emerged very much alive, pink and crying. I showed the mom her baby girl. The happy mother who was oblivious to her own close encounter with tragedy told the anesthesiologist that I should name the baby. I named her Mwaye. Her name is Fortune.

Sometime after meeting Mwaye is when I came to the story of the dead girl and her hungry baby and grieving mother. Monday night one of my friends gave me a large can of formula to donate to the nursery. When I was shown the woman holding the crying baby, I took her to the nursery, retrieved the donation, and prepared a small cup of formula while the nurses gave the woman directions. Once she was done feeding the baby and the baby’s eyes were dry and bright, another nurse came to tell us that the ambulance was ready to take her and the body to the mortuary at KCH. I carried the formula in one hand, the grandmother held the baby, my other hand lightly rested on her back. I could feel the bones of her ribs and her shoulder and her hips beneath the layers of tattered chitengis. I noticed her bare feet with their thick soles. I considered the can of formula, at a cost of over ten dollars each, I knew the newborn would not continue to eat this food without significant help. Before we even made it to the door of the hospital, tears began running down her wizened cheeks and her steps faltered. Several women, waiting in the halls for their own daughters, approached her, removed the baby from her arms to relieve the weight, and listened to her story as it came through her tears. I took the baby from one woman and she moved to support the grandmother who appeared close to collapse. She kept repeating, “I am alone, I am alone.” I considered the baby who was crying in my arms simply because he was a baby and wet. He had no concept of how his life was changing nor would he carry any memory of the day forward.

I had the nurses write down the village of the grandmother and tell her that I would meet her at the nearby health center on Tuesday with more formula. The 17-year-old mother died under our noses and now I’m trying to provide hope and help by giving cans of formula. One word - inadequate.

After the ambulance left, I returned to the labor ward and Deb asked me to examine a woman who had not been progressing since early morning. In the end, a clinical officer did a vacuum and I finished the birth. The small girl was blue and floppy but she picked up quickly with a little help. As I stitched the small tear on the mother’s perineum she asked me if her baby was ok. She told me that this girl is now her only living child after five pregnancies. I assured her that the baby was well and she smiled at the little bundle lying next to her.

The day before all of this happened, I went for a run with the large expat group. It was my first run in a long time. It was a nice run. As we ran through a field we passed a family of three. A ten-year-old boy followed by his grandparents. The boy walked in front, the grandmother, clearly blind had her hand on his shoulder. The grandfather, also blind had his hand on the woman’s shoulder.

No one to care for the young.
No one to care for the old.
They care for each other
even though they are not quite capable of doing so.
Even though their desperate need
of each other is a daily reminder of what
and who they have lost.
These visions are too much.
These realities are too much.
I don’t want to look away.