A Weekend Away

Saturday morning we set off early to Clement’s mother’s village north of Salima to attend the initiation ceremony of his stepfather as chief. We arrived in Salima by 10am and while rushing around buying sugar, salt, cooking oil, and changing money to take to the village, someone called asking for a ride to the ceremony on Sunday. In our excitement we had set off a day early. Although a bit annoyed with ourselves we decided to enjoy the extra time. We spent several hours lounging on the beach and then left for the village by mid-afternoon.

Clement’s mom, sister, grandmother welcomed us with hugs and laughter and while they prepared the grilled fish, nsima, and okra leaves for our dinner we sat with Clement’s stepdad James, drank tobwa (a fermented, but in this case non-alcoholic, drink made from sprouted maize or millet and sugar), and discussed the ceremony. Apparently when the population of a village grows past a certain point, it is common that a certain group requests to break away and become their own village. Representatives of the group approach the chief with their request and offer the name of the individual they want as their chief (either a man or a woman). If the chief approves, the request is passed on to the Traditional Authority. Once they have the approval of the TA, preparations are begun, the initiate must pass through a training and counseling process, and must arrange for the food and entertainment during the ceremony. In James’ case the process took more than a year. Every now and then my attention would drift from the conversation to the dogs chasing and wrestling each other, a little girl skipping across to her home, a man arriving with a live goat and chicken tied to his bicycle, a cat hunting flies, a girl in a green dress hopping on one foot shadowed by a little sister trying to do the same. These were sweet scenes.

It is winter now in Malawi and the sun sets early; by 6pm the only visible light came from the flickering cooking fire around which the women chatted and the children coughed. We were served dinner inside by a paraffin lantern and then Clement’s grandmother joined us to talk. The majority of what they said slipped by me but I loved watching her wrinkles gather into a conspiratory grin as she spoke and then watching them both convulse with laughter. When he translated her stories they came across more tragic than funny but I realize that transforming sad stories into entertainment is a common skill among survivors, irrespective of their cultural context. She said her house collapsed on her during the winter and now there is only one corner remaining that shelters her from the weather. She sleeps in that corner but sometimes, during a hard rain, even that corner floods and she wakes up and fetches a bucket to chase out the water. Smiling she said she is ready to die; she is ready to rest.

That night Clement and I slept in his mother’s two room hut on a grass mat on the floor. As I drifted off a group of men and a group of women took turns singing outside and I wished I had brought a tape recorder.

In the morning we took his grandmother to town to buy her shoes, a head scarf, and some other small items, we also gave her the 5,000MK (US$35) she said it would cost to build her a new sturdy house. When we returned I left Clement in the hut and wandered towards the women. I photographed them cooking, chicken, goat, nsmia, and rice in a long row of pots over open fires. They teased me and asked me to cook nsima but Clement’s relatives efficiently and repeatedly guided me away from the work towards a chair or mat.

The ceremony itself was not very exciting my standards, mostly because I could not understand what was being said. I enjoyed watching the crowd of a few hundred people and befriended several children seated near me who evidently found my presence more captivating than that of the TA. Clement told me later that the TA spoke about the roles of the chief, the importance of humility, the need to work with the people and to serve the people, the role of the chief’s spouse, and a bit on HIV/AIDS. Money was gathered for the new chief and for the Traditional Authority, Clement’s mom and stepdad were ceremoniously guided back to their hut, and the day concluded.

I know life in the village is difficult; it is also beautiful. I am grateful for the food and love and hospitality I was offered. I appreciate the value of each gift and will continue savoring them for time to come.

Punctuation

Thursday morning as I approached the door of Bottom Chikoti, one of the clinical officers, met me and told me that he had been called to see about a woman with a stuck breech. We walked in to find Msiska working with difficulty to extract the head of a baby whose limp body hung from it mother. The mother pushed, every vein in her face and neck expanding with effort, Msiska twisted and pulled, and a small crowd of students encircled them both. Finally Msiska was able to free the baby, the mother fell back, the crowd dispersed, I placed my stethoscope to the baby girl's cool chest and heard silence. I tried resuscitating her for a few minutes but after hearing about how long she had been stuck, I put down the bag and mask, wrapped her in her mother's cloth, and brought her to the bed for her mother to see.

Somehow as her body was born she rotated belly up; for a breech baby to deliver safely, she must be born so that as she emerges her belly is closest to her mother's spine. I was not in the room so I can't say why this happened, maybe the mother began delivering quickly without assistance, or maybe she was assisted but the midwife could not guide the baby to the proper position, or maybe she was simply left alone and found later with the baby in this position. I don't know how it happened but standing there in front of that pale motionless little girl I felt a wave of anger and hopelessness. This was the third baby who died in my first five days back in the labor ward. (Not counting a couple others who died later after surviving for a while in the nursery.) Each of them were preventable deaths. Each so final, so heavy. Each a permanent scar on the mothers' heart. More sadness, more pain in a world where life is already difficult. It is not my personal pain but the exhaustion and sorrow rested on my shoulders.

A few minutes later I found Rabecca sitting up on the first bed. I glanced over her chart. She was 24 years old, this was her fourth pregnancy but her previous three babies were all born very prematurely and died. The problem seemed to be that for some unknown reason Rabecca's cervix always began dilating early thus ending the pregnancy before the baby was ready to live outside of her. Fortunately this pregnancy, she was seen early on my Dr Meguid who had stitched her cervix closed and then removed the sutures only once the baby reached 37 weeks gestation. Just seeing her on the bed with her big belly was a hopeful sign.

The progress on her labor chart was not as hopeful. It seemed she had been stuck at 5 centimeters for some time and when I examined her - three hours after her last exam - I found her cervix still at five centimeters. I thought about the probable course, pitocin, possible c-section, days in the crowed post-natal ward. I put the thoughts aside and closed the curtains around her bed. I couldn't stand the thought of another sad story, regardless of the degree of sadness. I rubbed her back, watched her, and realized that her contractions were not very strong. I showed her how to stimulate her nipples (this helps release oxytocin, the hormone that causes uterine contractions). I stayed with her, kept the curtains closed, gave her water, and encouraged her. As we continued the nipple stimulation her contracts became stronger, I could tell she was exhausted, but she released herself completely to the waves of her body. Within 40 minutes her daughter was born, beautiful and pink. She let out a small cry and then looked around with calm. Rabecca beamed and snuggled her in close. I cleaned her up, helped her breastfeed then closed the curtains around them. Rabecca's birth carried me through most of the day. Everything I did was seasoned with the sweetness of knowing that woman can receive good care in this environment and they can have not only safe births but joyful and beautiful births.

Towards the end of the day, I noticed Ivy crying loudly on the last bed in the room. She labored with her third baby and a student stood by monitoring the baby's heart rate. At Bottom it is unusual for a woman laboring with her third baby to be so vocal. I placed my fetoscope on her belly and heard nothing but her own pulse. I asked two other midwives to check, they also heard nothing. I brought in the ultrasound machine and saw the baby's heart beating slowly maybe at 40 beats per minute, maybe at 20. I lost hope for the baby but an emergency c-section was ordered.

Thirty minutes later I was handed her baby; a large boy with no pulse. He did not respond to resuscitation. His head was molded in an unusual way and I thought for a minute that he had been positioned incorrectly inside but then the clinical officer conducting the c-section told us that the mother's uterus was ruptured. The uterus even as it was ripping continued contracting, pushing the baby - not out of the cervix - but out of the tear. This mother escaped with her life. I met her sister outside the theatre and asked a nurse to explain the situation. She was grateful. She saw the dead child. I went home ungrateful trying desperately to recapture the joy I felt with Rabecca. Trying desperately to make her the center and not merely punctuation.

At home I found Clement subdued. He said one of the students from his school had been hit by a car and killed the previous evening. He was a year behind Clement and they were not close, but friendly acquaintances. The students had just finished their final exams and this one had gone home to drop his belongings, then as he was returning to school, walking along the road in the dark, was struck by a car and killed. The driver brought him immediately to the emergency room and was met there by three close friends of the young man who happened to be on duty. They were unable to resuscitate their friend. He was one of four children, the only one to go to college, the hope of his parents.