Babies

Sisters

I am never short of something to write about, and theres a backlog of interesting topics I want to get to eventually – the markets, the prison across the road, HIV, my colleagues here, various cases Ive seen as outpatients, and more . The trouble is I feel compelled to report on the more dramatic stuff that happens at work and I apologise to anyone who is getting a bit sick of obstetric horror stories from Motta – I am sort of getting a bit sick of it myself but Obstetrics and maternal health is my profession and I didn’t enter oit because I find it boring, but because it fascinates me, you could say I love it, and Ive always felt  that what women do, in carrying and giving birth to our little ones, is astonishing and wondrous. It is such an extraordinary  thing to see a tiny baby emerge and take its first breath, and to set off so innocently down that long road into the future….

I suppose I am in a  somewhat reflective mood this morning because this week three babies didn’t get very far at all down that long road, something these poor people accept as part of life. Like maternal death, stillbirth and neonatal death is so uncommon where I usually work that each loss is seen as an outrage, as wrong and unfair, and often enough prompts  anger and a search for someone to blame, and dare I say, take to court. But here, as I was near midnight last night, I am thanked and people bow their heads towards me, and the midwives rub my back and hold my hand after a baby died, saying “it is good, you saved the mother” 

One of the babies that died this week belonged to the woman who nearly died herself from bleeding. Babies are not placed in their own separate little cots as they are back home, but into the bed with the mother, under the mess of scruffy old blankets, the mothers ragged clothes and wraps so its often hard to see exactly where they are, let alone how well they are. I am pretty certain midwives here make no attempt to check on them at any time – something which is left entirely to the parents.  So in this case, with so much drama going on round the mother, little notice was taken of the baby which you may remember had been delivered by one of the midwives using a “Kiwi Cup”, the suction device that goes on its head. Back home there is a limit to how long the cup can remain on of 20 minutes, for various safety reasons, and when I am using one there is always a midwife writing down the exact moment it is attached, when I am applying traction, recording if the cup is pulled off prematurely and reattached, and the exact moment of birth. Here the record will simply state “Alive neonate delivered with vacuum, APGAR Score 8/9, Birth weight 2900 gm”. Back home the combined medical and nursing notes describing even a straightforward delivery will fill a page or more! This is all a necessary part of whats called Clinical Governance, meaning all cases are liable for review and audit so standards are maintained and improved.

So what happened to this baby? Well, family became concerned after the focus on the mother had eased, and when I looked at his face peering out from the wraps, it looked deathly pale. Uncovering the baby completely revealed an undernourished very pale , weak neonate with a massively enlarged head, which I at first thought must be hydrocephalus, but then, if it had been, vaginal delivery would have been impossible. In fact after birth there had been massive bleeding under the skin of its head, probably from trauma assosciated with the delivery, not the more common cephalhematoma which can even occur after a normal birth, but whats known as a subgaleal haemorrhage, much less common and much more dangerous. The head was soft and spongey , a large spreading bruise obscuring the bony landmarks and fontanelles, it was 40cm in circumference and had probably been 34cm at birth, the baby needed what its mother received, Blood.  But nobody regarded that as an option here, and the baby was already close to death. And so it  eventually “expired” as did twins, one of which had been  born at home and the other in hospital weighing 900gms.

Cephalhaematoma - this baby was born at home and they were worried about the swelling.
It has  some sort of makeup on eyebrows and eyelashes

And now for some better news: Yesterday another set of twins was delivered and they have both gone home now and are well, but they also had an interesting story – the twin pregnancy was unrecognized until after the first one had been delivered, and then an arm appeared!  At this  point the midwife rang for me, and fortunately I was almost back at the house with my shopping, so I hurried home and raced across to maternity. Sure enough there was a hand but the head was in the pelvis as well, meaning a caesarean might not be needed if the arm could be pushed back to enable the head to come down past it. Such maneuvering and poking about is incredibly painful for the mother – back home we might consider an epidural anaesthetic or even just doing a caesarean – and this woman  grimaced and tossed her head from side to side  and sucked her breath in through clenched teeth but didn’t utter a sound while all this went on, and while I attached   a Kiwi Cup and then reattached it because the babys fingers got under it – and then with a couple of good pushes  from her and a careful pull by me, Twin II appeared in remarkably good condition.  As is usual here, 4 hours later she went home, as there was no abnormal bleeding and both babies were sucking well. More than likely she walked, and had bare feet.

Blood

The Delivery Room Door, the cleaners bucket and Mops; Theres no water to the Basin

I am sure even trauma surgeons don’t see as much human blood as we Obstetricians do. Every birth is followed by a couple of hundred mls of it, and sometimes much more, which is why, as I’ve mentioned before the commonest reason a mother dies is because of bleeding. Its why of all complications, bleeding is the one I hate the most. The death of a baby is terrible but the death of a mother is  the cruelest possible outcome of the human desire to bring new life into the world, happening as it does at the prime of a young womans life , snatching it away at the very moment when one of the greatest joys of  family life was about to be fulfilled, the birth of a baby, a new brother or sister, grandchild,   – the death of a mother creates a widower, motherless children, a huge hole that was supposed to have been filled with joy. If you ever visit India and the extraordinary Taj Mahal, reputedly the most beautiful building in the world, remember as you stand in awe that it was erected in memory of a woman who died giving birth - testimony to the impact of such an event.

In all my years of practicing medicine in New Zealand and Australia, I have never been personally involved in a situation involving a maternal death, though a small number of my patients have been close but survived – not so much because of good luck or good management on my behalf but because with the systems we have in place in the developed world, maternal death is very rare. For Australia, the latest figures are roughly one maternal death for every  12,000 births ( 8.4/100,000 births). In Ethiopia its possibly one maternal death for every 150 births, (670/100,000 births) though records are poorly kept and no-one is exactly certain what the real figure is. However a  government official visiting here a week or so back seemed surprised when, in answer to his question I said there hadn’t been any maternal deaths  so far this month! And there still haven’t been but I am writing this  today because I thought my run of luck or whatever it is was coming to a bloody end last night.



Maternal Mortality in Ethiopia : a sky scraper of death

What happened yesterday was this : firstly there is some sort of medical workers political meeting happening in Motta this week and most of the staff are at the Wubet Hotel participating in it. Absurdly, during the day maternity  is left to an experienced but – and I want to be fair – not one of the Best midwives we have, and myself, plus a gang of midwifery students, about a dozen young men and women who mostly stand around in their nice clean white coats with their hands in their pockets.. The midwifes English is poor and my Amharic is nonexistent so we have trouble understanding each other as well. However I have to say she is very sweet and hard working and yesterday, around lunch time peformed an instrumental delivery and a manual removal of a retained placenta on a woman having her third baby. I heard about it when I went back after lunch to see how things were – the woman in question wasn’t even in the ward when I had returned to my flat at about 10.30.  After lunch I was told everything was fine, but thinking about it now, I realize I am often told this.

At 4.30 I got an urgent call back to Maternity – the woman had collapsed! I was there in a couple of minutes and found the midwife trying to give the patient a syringe full of dextrose solution – maybe she thought her blood sugar was low? The crowd of students were standing round as usual, hands in pockets – “What happened?” I said “Any bleeding?” “No,” was the reply “No bleeding” and certainly you couldn’t see any blood anywhere, but then the woman and her baby were almost completely covered by  two coarse hospital blankets.  I threw them off – and beheld a lake of fresh blood and clots of blood filling up the space between her thighs – at least a liter probably nearer two, and then when I pressed my left hand into her abdomen I felt the top of the uterus way up above her  belly button, and swollen with more blood which, when I pushed down on the uterus as hard as I could, emerged in a huge torrent, another bucket of blood into the bed between her legs. She of course was in shock from all this blood loss, so we gave her fluids to get her blood pressure up, lots of fluids, blankets to keep her warm and special drugs to stop the bleeding. “Can the bed be tipped up? “ I asked “No possible” was the reply but when I pushed the bed out from the wall and went to the other end and felt round underneath I found the lever that made it possible – the idea is to have her legs elevated. And then I decided to wait to see how she would respond, though by now back home she would have been receiving a blood transfusion.  However there is no blood bank in Motta and the nearest blood bank is three hours ride away along a rough road – Bahir Dar. The other option was to try and get compatible blood from family members, something I had tried unsuccessfully to do on a previous occasion. I should have tried again but I didn’t, which was stupid, I don’t know what I was thinking, but as the bleeding seemed to have settled, and some urine appeared in her catheter and a weak  but fast pulse returned to her wrist, I incomprehensibly decided to just watch and wait. And yet she had undoubtedly lost  more than half of the blood in her body! What was I thinking?

And of course, inevitably, three hours later I got another emergency call – she was bleeding again, her blood pressure was unrecordable, she was semi conscious “Quickly come, she is critical patient” I grabbed my torch – it was about 9pm – hurried back with a sinking feeling and dread in my heart. When I got there, to my relief, things were not so bad : the bleeding was not returning, there was more urine in her catheter bag, the uterus was not refilling with blood - in fact she had eaten something and vomited. But I was snapped out of my stupor and realized we must get her some blood. She was horrendously anaemic and her pulse was 130. I rang the hospital doctor on call, Dr Yili  - I wanted to discuss getting blood – someone mentioned the  midwifery students – maybe they had a use after all! – or sending her to Bahir Dar, which would be a last resort.  Being Ethiopian, and knowing the system and the Hospital, Yili quickly sorted things out and a small crowd of extended family materialized from the dark to have their blood groups tested. I had asked for Oxygen but none was forthcoming until Yili asked for it, and about an hour later a man who I think was our patients brother smilingly gave up his forearm to a big needle and in a few minutes we had our first bag of blood. A few minutes after that it was dripping into his sisters forearm.

This morning she is still dreadfully anemic but we have no more blood to give her. Fortunately she is not bleeding any more and she will slowly recover her strength but I shall keep her in the hospital for a day or two more.

We are going to have to get better at managing post partum hemorrhage – all of us!

Two Wins

Pool Hall

The shoe-shine boy, Yemataw is studying road construction, and once he has that Diploma he wants to go to University. He is soccer-mad, much more intense about his team, Manchester United than I have ever been about the All Blacks. He knows all the players names, histories and positions, and all the scores and dates of matches , often wears his MU shirt, and in the evenings plays soccer on the field across the fence with the other local soccer fans. Recently he went to Addis Ababa for the first time ever, and a huge highlight was seeing a match at the big stadium there between two of  the Ethiopian regional teams. Last week when he got back he mentioned that on Sunday he would be watching the next Man U game live. “Which channel?” I asked wondering if I could perhaps watch it too, on my satellite TV which has been repaired, though I still hardly ever watch it. “Oh no, not TV, in town” he said. And then I discovered there are several places in town that are connected to just about every available satellite TV station in the world – so you can imagine what my next thought was: The Rugby World Cup final! I made him take me to one of these places to see if they had access to the RWC final Live and they sure did! It came via a South African TV station, and the only charge for watching it would be something to cover the electricity – I gave them $1.50 – and it would start at 10am Sunday. The venue had a slightly seedy atmosphere to it, the front room containing a pool table and walls decorated with images of busty white women and lots of cleavage, while through an open doorway at the back was a small darkened corrugated iron shed with bench seats lined up facing a decent sized plasma TV. And there I sat the next morning, the sole All Black supporter – indeed the sole Rugby supporter, but I watched the Final LIVE!  Man was it a tense match!  The few locals who drifted in were more amused by the scrums and the agony they could see me going though than the drama on the screen. And to think I could have watched the Semi Finals if I had only heard about this place sooner!

Dr Melesse Gardie and the Pharmacy Storeman handing me the Misoprostol

The other big win was the arrival at the hospital of a consignment of Misoprostol tablets. Dr Melesse had arranged for them to be supplied from a providor of  what they term “safe abortion” resources, on a continuing basis. Complications of “back street” abortion are a huge killer world wide, and no doubt here in Ethiopia, so I am all in favour of safe abortion., and very pleased to have their support. Apparently abortion is legal here in cases of rape and for a few other indications which seem to make it reasonably accessible. The midwives have already alerted me to two cases of what were probably complications of back street abortions, but fortunately none was serious. One of these women was HIV positive, a gorgeous looking 18 year old they told me was a local sex worker. Clearly given her recent pregnancy, her professional activities  are not “safe” and neither was her abortion. Dicing with Death on many fronts. 

Updates

The Chook we paid 83 Birr for at the Market

Sadly, twin II “expired”. He was still alive yesterday morning but the tube had come right out and no-one seemed to know how. He wasn’t receiving his Kangaroo Care either and though it seemed  everything I was doing was being sabotaged I didn’t really want to give up on him. “One more try” I thought, so I put the tube back down, and reminded his mother to keep him warm and to keep expressing milk for him. When I went back a few hours later he was pale and cold and barely moving - he was dying, it was too late. I removed the tape and the tube and his “hat”, and we told the mother he was going to die soon, she should take him home and that’s what she did.

I’ve since learned from Juliette, an Oxford Anthropologist  who made a lovely surprise visit here a couple of weeks ago – and saw me deliver a baby being born on the path outside maternity, her first birth she later said  – that in Ethiopia twins are not necessarily seen as cute and a blessing like they are in the west. And today when I diagnosed a set of twins in a woman coming for a routine ultrasound I discovered that truth for myself – she was far from overjoyed at the prospect and the midwife confirmed it’s a common reaction, the main reason being economic. The midwife then confided that Meteke, who lost the twins over the weekend, had not really wanted Twin II to survive, did not like nursing him on her chest, and didn’t even want to look at him as she was afraid of his strange  premature face and tiny body: to me , he looked sweet and loveable. I wondered what sort of life Twin II would have had if he had survived in that family. The midwife did also say however that if the twins had been hers she would have wanted them to live and be healthy, and so would other women. I am still trying to decide what I should do next time a mother here doesn’t really want her premature baby  to survive – I think we still have a duty to care for that baby but maybe we will offer it differently. Theres so much to learn but its fascinating.

Actually, last week a woman gave birth to a lethally abnormal baby – it had anencephaly which I had diagnosed on ultrasound – and I was told that women giving birth to babies like this believed they were being punished by God.  What would we think of a person who in order to punish a woman would deform and kill a child? So why is it somehow acceptable if God does it? Religion is crazy!

And Tarike, the woman with eclampsia? Well she slowly regained consciousness, as her presumed swollen and irritable brain started to recover, she went through a night of extreme agitation and wild yelling and thrashing about till we seadated her again, at one point she seemed to be unable to see but that has passed, at another she reported hearing voices, but now she is nearly ready to go home, though I am not sure how complete her recovery will be. She had been in Grade 11 at school but today her language and behaviour was more like a 4 year old, grinning and passive and almost mute. She has obviously sustained brain damage  but a young brain is remarkably good at fixing itself so hopefully in a few months she’ll be back at School.

The new Tank going up....

There have been developments in regards to the water tank which for months was going to be fixed “next week” Men turned up one day and pulled down the  half collapased wooden tower, cleared space and retuned the following day with a brand new  welded steel tower and a new plastic 1000litre tank. Concrete was slopped around the four skinny legs and a few days later they manhandled the tank up to the top and reconnected all the pipes. And the next morning the tower buckled and bent under the weight of the water, the pipes all busted apart and we are back to square one.

...and coming back down.

And the chook, thanks to Yemataws butchering skill is now six frozen meal size portions in my fridge.

Twin II and the Meaning of Life

The White Board lists our Patients

There’s a light on a stand with wheels in the delivery room that’s supposed to be used to help you see what youre doing if a woman needs some stitches after giving birth. The wheels are so filthy that they don’t turn  but in any case I was told it was broken. In the ward office theres a whiteboard which one of my predecessors procured from God only knows where, but when I got here it hadn’t been used for ages because the whiteboard markers were all dried up – more likely because nobody bothered to put their caps back on after using them – the pens  with their stiff dry felt tips and their caps were amongst the litter in the desk drawer. Someone else arranged a system for sterilizing equipment using a series of large plastic bowls – but they all have dead insects floating around in them. When the cleaners come, they have a small bucket of water and just seem to smear the mud and filth evenly round the room with thier putrid mops rather than actually remove much of the dirt. There are so called "safety boxes" - vital in this HIV contaminated world - into which broken glass phials and used needles are supposed to be placed but they are left scattered all over the place. And yesterday, a woman gave birth to twins  about 6 weeks prematurely and one died after seven hours, and the other, which was still alive when I arrived  in the morning to do a ward round, was having nothing done to help it, neither to feed it or even make sure it was warm. And yet I know the midwives know about basic infant feeding and something called Kangaroo Care where a mother keeps the baby between her breasts, close to her skin so her warm body can act as the incubator to keep the baby warm.

Initially, when the midwife informed me a woman had delivered twins in the night, I was again wonderfully impressed with their practical skills and confidence. Like eclampsia, twin vaginal delivery is a high risk situation – in fact in the west the practical skills of managing the vaginal delivery of twins are being lost, as an increasingly nervous and risk averse obstetric profession delivers more and more babies, not just twins, by Caesarean Section.  So yes, I was impressed! But it was discouraging to find nothing was being done for  the surviving twin, which weighed 1.5kg at birth and still had a chance..



A newborn healthy baby

I worked out the amount of milk the baby was going to need at frequent feeds and the midwives found a feeding tube which they then inserted into its stomach.. We sat the mother up and encouraged her to express milk for the baby and we got 6 mls  and put it down the tube. The mothers – as is usual, - filthy dress was closed across the front so we found an old hospital gown with buttons down the front and she changed into it so that the baby could be nursed on her front, and I found a little cloth bag that we put over the babies head to try and keep it warm….progress ? I left clear notes as to when the next feeds were to be given, and how much, and went to the market with Yemataw the shoe shine boy to get a chook.

Later, when I returned to check on the baby, one midwife said all was fine and the other said it was vomiting so they had stopped feeding it. I went to see what was happening and the mother was asleep with her back to the baby which was on the edge of the bed, and there was some milk in the feeding tube but the milk was obviously dribbling out the opposite nostril from the one the tube went down. Now the thing is I have never had any neonatal paediatric training, and no experience whatsoever of  this sort of thing, but I decided that the tube must not be far enough in, so I peeled off all the tape holding it in place and poked the tube down a few centimeters further. This time the milk stayed down. I rewrapped the baby and gave him to its mother who by this time was awake.

Later, we did an emergency caesarean section for a woman who had been in labour and walking all day to get to hospital. She knew  she would need a caesarean because her first attempt at having a baby resulted in its death and the development of a fistula, which had since been repaired. It was a difficult caesarean and the blood loss was excessive but there was no blood to give her. But when I went to bed, and during the night it wasn’t her that was on my mind, it was the surviving twin , and more particularly what seemed to me the indifference displayed by the midwives and even the mother to its survival. Thinking about the whiteboard – for which I got new markers - and the Light which just needed a new light bulb – which I got for it – all those insects in the sterilizing bowls,  the "cleaners"  the glass and needles, I started to wonder what the hell am I doing here?

I can see that if you work here year after year disappointment and death can become easy to accept and to feel we have so few resources theres no point in trying.  What I would like to enthuse the midwives with is the idea that we  do actually have resources, not many but some and we should do the very best with whatever "stuff" we have, and whatever learning and skill we have. but after that, its up to the Gods..

I expect twin II will have "expired" by the morning, the Gods being what they are.

Eclampsia



The Game

I was walking back from the market, about ten minutes from the hospital, when I saw one of the midwives heading in the opposite direction. A couple of hours earlier we had seen all our patients together and all was well. We greeted each other and then he said “Doctor, I have admitted one lady with eclampsia, she has  magnesium sulfate and  hydrallazine, her BP is control, she has catheter and she is 6 centimeters”  This was pretty shocking news –  eclampsia – which is when a pregnant woman has convulsions because extremely  high blood pressure is causing her brain to become swollen and then perhaps start bleeding - is one of the most feared obstetric complications and can readily result in maternal death. Eclampsia occurs very rarely in the developed world but is a frequent killer in places like Ethiopia because women frequently receive no antenatal care the most important function of which is to detect the signs of imminent eclampsia. I mentioned a woman with these signs in a post a couple of weeks ago – she had Pre-eclampsia and we sent her to Bahir Dar.

Remarkably though, using the excellent simple and clear protocols one of my predecessors developed and taped to the wall in the office in Maternity -  the midwife in Motta had given this desperately ill woman exactly the right treatment. I was amazed at how expertly he had dealt with everything and not felt any need to ring me. Back home such a woman would usually be managed in a sparkling clean high tech intensive care unit, be attended by various specialist obstetricians and obstetric physicians and intensivists, along with their retinue of registrars, resident and student doctors , midwives and nursing students,  have a huge list of  laboratory investigations done and have them repeated 4 or 6 hourly, and be the focus of  much discussion and concern. This woman underwent no laboratory investigations and had seen one midwife and was nursed in a filthy room with dirt and litter and a caked and stinking  bedpan under the bed and flies coming in the window!

Intensive Care Bed

I hurried to the hospital. I was dismayed to find only student midwives in the unit, and no further observations had been taken of blood pressure, the baby’s heart rate or other vital signs. Worse, she was still fitting, and family members were crowded round her bed trying to stop her from falling off the bed as she arched her back and jerked her limbs violently. It was a ghastly sight. I shouted at the students to go and find the midwife and bring more Magnesium, and fortunately one turned up almost immediately and we gave her a top up dose, again as described in the protocol; whereupon she lapsed back into a state of deep unconsciousness.  I was told the convulsions had started at home, 60 or 70 km away the evening before  and they had bought her to Motta on the morning bus. I remembered  a 15 year old indigenous woman I once looked after in Darwin - she had a convulsion in a much more remote  community – at least in terms of raw kilometrese – but she arrived  at  our huge multistory modern hospital  in about 4 hours by helicopter! What a contrast! This poor young Ethiopian woman had been fitting on and off for nearly 24 hours -what I feared was that she might have  already sustained irreversible brain damage, and she might never wake up. She had not received any antenatal care and we knew nothing else about her pregnancy.

The labour had started spontaneously, but if it hadn’t we would have wanted to get it started, as the only definitive treatment of this killer condtion is to end the pregnancy. When I checked, labour had progressed to the point where I was able to quickly deliver the baby , but to our further dismay, though alive and active he was obviously far too premature to survive in Motta – in Darwin he would have been fine after a few weeks of “expensive care” All we could do was  wrap him up and put him on the bed with his mother, though she was unconscious and in an hour or so, his short little life came to an end. He weighed 1200 gms, about  2.5 pounds and had been born perhaps 8 weeks too soon. The family later took him to the church then returned his body to the hospital for disposal.

A drawer of dead insects

As for his mother, Tarike, there wasn’t much more we could do for her either, other than monitor and treat her blood pressure and fluid requirements, continue the magnesium for 24 hours and hope she might start to improve, and not develop any further complications – these can include liver and kidney failure, bleeding problems, brain damage, and of course death from the swelling or bleeding in the brain, but we had no way of testing for any of this. However for the rest of the afternoon her blood pressure remained stable and her kidneys seemed to be working as urine trickled slowly into her catheter bag.

I asked the midwives to check her every hour, and did myself as well for the next 4, and then I went home. I was hopeful by then she would survive.

The Involuntary Vegetarian

1000 ways to eat Beets

Finding food I can enjoy is a bit of a struggle here but I have been helped and reassured by remembering  dietary advice my father gave me years ago. He said its important to have a varied diet so “if you have Mash (mashed potato) and bangers (sausages) one week, be sure to have mash and mince (minced meat) the next “Actually I would LOVE some NZ beef sausages or some mince right now. I am more or less vegetarian, except for twice when Ive ordered the meat sauce with spaghetti at Wubet. I eat lots of bread which is sold as small rolls and are fresh and tasty but theres no butter or cheese so I fill them with slices of tomato and green pepper, or a banana, or, as a special treat a thin smear of  delicious strawberry jam from a ¾ full jar that Fritz left behind. And last week I  bought a Kg jar of Peanut Butter from Jamals store in town. Yesterday I boiled a huge beetroot for an hour or two and for breakfast today filled my roll with slices of it cold. It was a bit fibrous but tasty. For lunch I will boil two eggs and put them in the roll. I also drink lots of bottled water and have coffee once or twice a day. As for fruit, I have eaten some oranges but haven’t  bought more because when you eat one you spend most of the time  spitting out a mouthful of pips and indigestible fibre for a tiny dribble of juice. I have eaten injera on a few more occasions and I am nearly ready to order a full meal of it one of these days at the Wubet. Lately for my evening meal I have been having either boiled rice or Mash with raw onion mixed in, whilst working my way through a cabbage.  I slice it up and either boil or stir fry with onion tomatoes and peppers with a dash of a Thai red Curry paste also left behind by Fritz – or his predecessor perhaps? Again I am trying to  spin that out and make it last.

I have been invited by various colleagues to several “Coffee Ceremonies” in nearby Hospital flats. These are essentially social events put on with the slightest excuse, where traditional coffee is brewed in a pot on a special charcoal fired burner on the floor  and served sweet and black in small cups. The floor on each occasion I have attended was always strewn with a layer of freshly cut long grass with a few bright red flowers scattered here and there. Sometimes there is something to eat as well but just a snack, such as pieces of bread or freshly popped corn. Everyone lies about on the floor and on the few chairs or bed and chats and laughs away in the smoky gloom till the coffee is all gone.

Bananas at Coffee ceremony

Ethiopians seem to be very sociable people, and always greet one another with great affection. The traditional handshake seems to be grabbing the outstretched hand by the thumb and then bending forward so the two right shoulders meet.. Homophobes would feel uncomfortable here I am sure as men often wander along the street holding hands or with arms around each other – but I was told there are no gays here, theyre in Bahir Dar! 

Simegnew and Monemon , two wonderful midwives

I am a reasonably touchy-feely sort of guy I think, but I feel a bit weird walking through the hospital holding hands with one of the other Doctors! On the other hand if one of the budding Ethiopian supermodel midwives wants to give me an enthusiastic hug and hold my hand, well I just do my best to put up with it.

Awesome All Blacks

The Haka before wacking Wallabies

Really, its quite fantastic that we have any internet connections at all way out here, so I shouldn’t complain. Out here, if it wasn’t for the Internet it would be easy enoughl to feel isolated and cut off from the rest of the world, from my family and friends especially, and from sources of advice and information  and support that one ordinarily relies on at work. But I don’t feel cut off – well, maybe  a little bit!. The wireless connections here are CDMA – I am not sure what that is exactky but I remember we had CDMA phones about a decade ago in Australia, - its much faster than dial-up, which we used to thnk was amazing – but  Ive been spoiled by  broadband. More frustrating than the slow speed is the way in which the connections drop out altogether from time to time, so that the photo Ive been uploading  for 20 minutes – yes its that slow - just disappears, and its even more annoying when its an email  or a blog Ive just written that disappears. So I have learned the best approach is to write the email in Word then cut and paste into Gmail .or the Blog so at least if it disappears I have a copy and don’t need to rewrite the thing! The expletives emanating from my flat  have reduced to a minimum.

On the weekend I was counting the hours down to the All Blacks v Wallabies semi final. It was potentially a great clash, the Wallabies having a perfect record over the All Blacks in World Cup Rugby, and the All Blacks 25 year unbroken run of wins against the Wallabies at Eden Park, the loss of Dan Carter, the worries about Richie McCaws foot, the inconsistent brilliance of Quade Cooper – I just SO wanted to watch it live. In fact there are internet pay sites where  in the past I have watched live Tests, and early last year the last Americas Cup Race – Oracle vs Alinghi – but the connections here are just too slow for that.
And then , just as the game was about to start and I was logging on to the Sydney Morning Herald website which runs a “Live Blog” - ie written commentary updated every 2 or 3 minutes- I suddenly remembered Internet Radio! A quick Google search for NZ Internet Radio and next I was listening to live Commentary of the game : Fantastic – especially when combined with my hand drawn rugby field, posts at each end , the ABs and Wallabies territories marked and lines and dots where the ball was kicked to , where there was a line-out, a scrum and the  score and time scribbled along the edge of the piece of paper – I was almost there I tell you!. The commentator by the way was brilliant and I can understand why some people watching games like this live on TV turn the sound off and the Radio  on – the radio guys put so much more into their  commentary and get so excited! The connection dropped out of course, about three or four times and with ten minutes to go I had an urgent call to Maternity but by then I think we all could see the All Blacks were not going to be beaten.

Delighted All Black supporters in Motta

At the inaugural World Cup the Final score was All Blacks 29  France 9. The All Blacks skipper then was David Kirk, a colleague of mine at med school. Now  France and the All Blacks  face each other again. I suspect next weekends Final will produce a similar result given that the French could only beat Wales with one man down by 1 point, but then again France have unexpectedly booted the All Blacks right out of the World Cup on two occasions in the past. But, whilst waiting for the Fat Lady to sing, New Zealand must be pretty buoyant this week. Their win over the Wallabies was brilliant.

Village Life

Motta Street Scene

Early morning is my favourite part of the day here. After waking just as the sun is rising, its wonderful to stand outside with my Ethiopian coffee and just listen to the sounds of village life. The thing I notice most of all is the com-lete absence of traffic noise and I have never heard or seen a plane  anywhere in the sky which is clear and pollution free. Instead what I here are the bleats and brays of goats sheep and donkeys, the occasional bullock bellowing and often children laughing or calling out. There are lots of small bird calls and coo-ing from pigeons. If there is little wind, smoke from cooking fires hangs over the houses across the field and I often catch a woody, eucalypt aroma if the wisps of smoke drift my way. There are always a few people about  walking quietly along behind their goats or bullocks as they move them off to pastures somewhere, but there are no fences other than the one surrounding the hospital compound. Village life can seem idyllic at that time of day, and maybe even for the villagers for a brief time it is.

  A row of houses and a pile of tef straw

One morning, walking back to the flat  after  checking the maternity ward, I heard what I thought were gunshots. In fact it was whips being cracked as  several  local farmers were ploughing , using pairs of bullocks to pull a wooden plough with a single blade, technology that must be many centuries old. . A couple of other people following behing were scattering seed, but I couldn’t work  out what the crop would be, perhaps Tef, the crop whose tiny seeds are ground into  powder, mixed with water to ferment a few days then cooked to make injera the staple food of Ethiopia. On another day I saw those same bullocks  being made to walk round and round on a thick carpet of  harvested grain – not sure which type – and afterwards, in a light afternoon breeze, it was separated from the chaff by tossing it into the air.  The stalks are then piled into a a very heat pile, a hay stack near the house and among other things its used as animal feed. It is also used as a building material by mixing it with mud to make the thick plastered walls of village houses.

Mixing up the mud and straw

I saw two women and two men preparing this plastering material one day, walking round and round in knee deep mud, trampling in the straw scattered across the top. A week later they have yet to start plastering the deteriorating walls of the house beside it – perhaps they are waiting for it to stiffen up a bit.  The mesh into which the mud and straw is pressed is made of branches, and the plastering apparently needs redoing about every ten years.– the raw materials are all free and biodegradable, and of course you do it yourself. A pretty good example of recycling and sustainability, the carbon footprint of poverty is probably invisible.

Good things happen too!

All young obstetricians in training these days are given lots of formal instruction in the use of ultrasound , and they all are really good at it but when I was trained there was very little formal training. I had my own machine and taught myself the basics but for important things it was always easy for me to refer the patient to an expert down the road. Not here! There is, remarkably, a rather good little portable ultrasound scanning machine brought here I think by one of the Barbara May Foundation doctors. It is kept in a locked room, and I use it every day for various things, mainly trying to date the pregnancies of women from the antenatal clinic. Unfortunately dating a pregnancy  by ultrasound is quite inaccurate when it is done as late in the pregnancy as these women  mostly are when they turn up for care, if they do at all. One day I was asked to do an ultrasound scan on a 72 year old man – his scrotum was swollen to the size of a football, though I am sure he wouldn’t have liked anyone to kick it! I had never done a scan on a scrotum before but it clearly showed the enlargement was mostly cystic : a huge hydrocoele that could at least be drained to give him some relief.

I decided to scan the lady with pre-eclampsia. Her BP was still under control and now it was time to consider getting the baby out by making the labour start but being six weeks premature I wanted to delay as much as possible. Unfortunately even with my crude scanning abilities, I could see trouble was brewing for the baby as there was hardly any fluid left around it , and the measurement around its abdomen showed it was very skinny – the baby was starving in there and was at risk of dying any time soon. Other tests I would have usually done were unavailable to help but time was running out.. The dilemma was that being born 6 weeks premature, and being undernourished as well placed this baby at serious risk – and we had a total of Zero neonatal expertise or even basic equipment such as a humidicrib or oxygen in Motta. I discussed it with the midwives : they  reckoned the baby had maybe a 50:50 chance of surviving if we delivered it here – back home survival would be exceedingly likely, close to 100%.  Furthermore, I then discovered we had run out of the drug used to start labour, called “Cytotec”. Supplies had been brought in by visiting overseas doctors like myself, - though I hadn’t - and now they were all gone. We explained all this to the patient saying we would need to transfer her to our referral hospital at Bahir Dar, which at that time I understood to have better facilities – subsequent events have led me to suspect otherwise – it is certainly a lot bigger hospital with many more doctors but I am not certain the standard of care is much better – but in the event, that is where she went with a letter from me detailing very simply and clearly what the problems were and what needed to be done. I subsequently heard they also had no Cytotec and the baby was delivered by caesarean section. I have no news as to the fate of the baby.

Lots of babies do well, like this one the student midwife is giving its first bath

This incident  with Cytotec illustrates perfectly the dilemma that is created by welfare handouts. I am all in favour of welfare but what it can sometimes do is undermine the ability or perhaps the motivation of the recipients to develop for themselves a sustainable long term solution to the problem – in this case, the supply of  this particular essential medication.

I therefore went to see the Medical Director and explained the vital importance of this drug in Obstetric care – it is used for starting labour, but much more importantly it can  powerfully treat bleeding after childbirth – the leading cause of maternal death – and thus can be  a truly life-saving treatment. It is also a surprisingly cheap drug so there should be no excuse for local or regional authorities not to ensure the hospital has adequate supplies of it. Till now of course there has been no need for them to act because overseas doctors have always brought it with them. We had a meeting with one of the hospital managers and with his support a process is being started that hopefully will result in Cytotec being supplied locally henceforth. That would be a genuine enhancement to the local service, so I am continuing to harass them with enquiries about progress. I shall report back

Maternal Mortality

Sebsabe goes home after a nightmare end to her first pregnancy

It took two days, but Sebsabe got better and on the third day the family wanted to take her home. So we took the dressing off her caesarean wound and it had had healed perfectly. And her tummy was nice and soft and the pain had gone so I agreed. Her mother then put on a blue dress after peeling off the large grubby green dress she had on and  she gave  it to Sebsabe to squeeze into. A couple of quick pictures a few smiles and they were gone, but not before I made the midwives reinforce the absolute necessity for Sebsabe to come to hospital next time she is pregnant and especially as soon as the labour pains start. I think they got the message.

Meanwhile, we had two women with complications following successful births at home somewhere. One had an infection and needed antibiotics, and the other had sustained some bladder trauma and couldn’t pee. When a catheter was inserted nearly three litres of urine drained out –she must have been in awful pain. What was also  interesting about both these ladies was how pale they looked, and when we checked their blood counts, the results  even surprised the midwives. Back home the normal blood count  after birth would be above 100, and above 120 in a normal healthy adult woman; below 70 is severe anemia usually treated with a blood transfusion. Our two patients blood counts were 25 and 45g/L – testifying to what  must have been horrendous bleeding  and a terrifying scene at the time of the birth – they were both lucky to have survived! Bleeding at the time of birth is  the biggest single cause of maternal death world wide, accounting for about 25% of the 350,000 deaths a year – that’s about one woman bleeding to death somewhere in the world every 6 minutes. The second most common cause of maternal death worldwide is infection, and about as many die from complications of unsafe abortion.

Clearly these women would benefit from a blood transfusion but there is no blood bank in Motta. However, family members sometimes have compatible blood so we sent all available family for testing but unfortunately there were no matches. Our next option was to transfer them to Bahir Dar Hospital where there is a blood bank but the cost of transport was 800 birr – one family had enough but the other didn’t – hers was the higher of the two results so we just had to give her Iron tablets. I could perhaps have used some of the BMF money to help them out, but decided not to as I knew in time if she took the iron she would recover. If she had been septic like the other woman, or if her bleeding was continuing I probably would have, because recovery from sepsis is greatly impaired by anaemia.

At home these events are called Critical Incidents and each becomes the focus of  close investigation and review. They are infrequent even in big institutions. The  only time I ever saw a woman with such a low blood count up till now involved a Jehovahs Witness in New Zealand. She also had an infection and kept bleeding, till one night she decided to have a transfusion – I think the blood count by then was 18 - she said she could feel she was dying and suddenly she didn’t want to lose her children. Good on her! Damn stupid religion if you ask me – as usual in organized religion, it’s the poor women who suffer and the men parade piously round burdened by none of the  reproductive hazards that women have to put up with. I am so over organized religion!

The spooky thing is that these anemias and horrendous near deaths from bleeding only came to light because of other problems – I couldn’t help but wonder what other nightmares are happening out there unreported.

The Learning Curve



Etewa and her mum



On Wednesday morning Sebsabe was unwell, Her stomach was distended and tight and she was in pain. I felt sick at the prospect of what might be happening inside her abdomen and cursed myself for not listening to what the midwife had said the day before, not to feed her, to wait till her bowels were working again. Stupidly I had completely failed to recognize the obvious huge difference between my usual post operative patient back home, a well nourished healthy and  vigorous westerner, and a chronically  malnourished, depleted worn out and sick young poverty stricken Ethiopian. One step forward four backwards! And now was she about to pay the ultimate price for my stupid arrogance?

Was an X-Ray possible? “No it is broken 5 months” Oh my God! My heart sank further.

“I’m so sorry, I should have listened to you yesterday” I said to the midwife.

Well, there was nothing more to do except stop her eating and drinking, keep the drip running, give her some antibiotics and wait. Maybe they would pray, but I would not pray to a God who would let that baby come sideways. I would be angry at such a god, but I was angry with myself, and scared for Sebsabe.

But I was not to be permitted the luxury of wallowing in self pity. A woman arrived by stretcher from somewhere out there, she had been in labour a long time, the baby had not come out, and if I had thought Sebsabe was as sick as you could be in labour, I was shocked at how much worse this little woman was. Sebsabe at least could move and cry out, this one was silent and still, breathing quite slowly with deep sighing gasps, barely able to move her head from side to side, or open her eyes. She was almost unconscious. She had no recordable Blood Pressure and the pulse at her wrist couldn’t be felt. The heart beat that we heard was fast enough to be a baby’s, but it was hers, and a scan quickly showed another dead baby. But first of all we had to try to revive the mother with intravenous fluids. Again the midwives proved their exceptional practical skills quickly finding a vein even though she was so severely dehydrated and “shut down” and her arm didn’t move as they searched with the needle. We squeezed the bags of fluid into drips in both arms and then I examined her to see why the baby hadn’t been born. It was a “brow presentation” which means instead of the baby having its chin tucked in, like you do when pulling a tight jumper over your head, it was extended so that a much wider diameter was presented to the pelvis, and it wouldn’t come through. The forehead was all swollen and spongey. Brow presentation is a rare situation but in the west usually recognized in early labour and easily treated by safe caesarean section long before things get to this ghastly state. But here, in this horrible predicament caesarean was not an option. It would kill her for sure.

We took her down to the Delivery Room and placed her on the delivery table. She barely new what was happening. I thought I should try to deliver the baby with forceps if I could somehow change its position but within a few minutes I realized I could not. I looked at Mesaye, a horrible dread in my guts, knowing what he was going to tell me “I think you will have to do destructive delivery Doctor“ he said. And he handed me the instruments.

I have to say that Mesaye and the others there were unbelievable in the way they helped me and assisted me to do what certainly is the most gruesome thing I have ever had to do. At times they wanted to step in – they had already seen me cry once - but I insisted I would do it, it was my job, I needed to learn and I would be OK. And so I was. But the baby went to the incinerator with the placenta, too awful to even look at, and still hardly a murmur or movement from its desperately sick mother, whose family carried her back to bed number two.

But against the odds our patient, Etewa, survived. We had given her 4 litres of fluid in the first two hours and at the end of it a tiny amount of urine appeared in her catheter, as before, mostly blood but as the hours went by the blood was more and more diluted with urine. The next morning she was still terribly weak and unwell but I could feel the pulse at her wrist, and she muttered a few words. Her poor undernourished mother nursed her continuously, feeding her and climbing onto the bed to embrace and support her from behind, in a room where the mothers in the other beds had babies to feed.  At least Etewa had her life, but theres no grief counseling or social worker support for her, no farewells for the baby, just a grim life of poverty waiting for her to return.

Tuesday

I try to get to maternity around 8 or 8.30. Formal “Rounds” – where all staff meet to discuss progress and management planned for each patient  in the office and then at the foot of the bed – don’t seem to have caught on here. Neither have documentation or Filing, so nobody really is sure who is in the unit and doing what, and no individual midwife seems to be responsible for anything in particular. The medical records, such as they are, are haphazardly strewn across the desk and a dusty shelf in the one other piece of ward furniture, a wobbly old book case. Inside the drawers of the desk is a mess of bits of paper, old documents, an empty drug carton, and various other items that mostly need to be put in the rubbish. It’s the same on the bookshelf. Someone tried to get a system going using a whiteboard, which is still on the wall but the markers have all long ago dried up.

So after rummaging about and assembling the files and determining which belonged to women still in the unit and which belonged to women sent home or seen  casually and never admitted over recent days, we, that is up to three or four midwives and myself set off to try and see everyone. Firstly though , on this occasion I gave to Mesaye, the male midwife who I had worked with during the night, the remaining birr to settle the account of Sebsabe..

Mesaye, I should say is quite a frightening looking fellow – he is darker skinned than many, and short, and he is blind in the right eye which is completely white with corneal scarring. However he is an excellent and hardworking midwife and I have huge respect for his experience and wisdom. It has been wonderful the way he has offered suggestions to me at various times to help me find my way – so lacking in ego or a need to engage in any sort of power struggle.

We saw the woman with pre-eclampsia – she was obviously getting her blood pressure medicine and was feeling fine. And next we entered the small room where Sebsabe was. The poor thing was naked but covered by her own coarse and grubby blanket, now trying to recover from the traumas of a prolonged labour, the death of her first baby and major surgery. I felt terribly sad for her. She was still unwell and in pain but her husband and mother and other relatives, all dressed in filthy rags were crowded in to look after her, using god alone knows what resources, but it was their responsibility, and they were doing what they could. Her urine was still heavily bloodstained but otherwise she was stable. I suggested she could have fluids to drink – this is usual practice in the west – but one of the midwives objected. It was my second day at work and I should have listened to her but didn’t – yes she can drink I said, and ordered her antibiotics and a blood test. A lot of talking in Amharic followed, back and forth, and I asked Mesaye what was going on. He had just informed them that I had paid off their account, and with that the old grandmother and a man perhaps her father threw themselves at my feet , wrapped their arms around my legs and started kissing them and crying out. “Please, no” I said and bent down to them, overwhelmed, and couldn’t speak, tears welling up in my own eyes.– I just felt so sad for these sweet caring people. It was terrible that their poverty and their need was so great that  that such a tiny gesture could mean so much and be so gratefully received.  


Bed One



First Night at Work

Women in labour can be carried many miles on homebuilt stretchers like this

I couldn’t really understand what the midwife who called me at 1.30 am was saying – mobile phone transmission seems quite distorted sometimes and also doing their best to speak my language is often only partly successful but it was obvious I should get dressed and go in to maternity, which I did, by torch light

,

When women first arrive they are assessed in an open room that has two more of those clapped out beds in it and even more dirt on the floor because it is right by the front entrance to the unit. I have learned already that if  there is a cluster of old women and men gathered about the entrance to the unit, it usually means trouble within. A further clue as you approach will be an empty jerry built stretcher made of a couple of stout  branches - the men will have carried the woman in distress to the hospital on it, sometimes from many kilometers away, many hours  tough walking along rocky tracks and roads, often with no footwear and almost all dressed in worn out dirty rags.



Waiting outside after bringing a mother on a stretcher, barefooted

And there they were. Inside, a woman was groaning and rolling about on the plastic mattress, the midwife and a relative were with her, and it was obvious she had been in labour for a very long time and was exhausted almost to the point of collapse, with sunken cheeks and her dry lips stuck to her teeth. The real problem was obvious almost immediately – all she had managed to deliver after all those agonising hours, maybe even a day or perhaps two of labour, was the right arm of her baby, hanging between her legs, purple and swollen. The baby had been trying to come down sideways and now its shoulder was rammed down into the pelvis and its head pushed across to one side. The baby was dead and the mother would die as well before too much longer without help. This was something I had never seen before: this scenario just would never happen in a modern country because care would be available right from the beginning of the labour. The abnormal presentation would be recognized and the baby delivered promptly by caesarean section  in perfect condition and both would go home in 5 days probably never really appreciating the fate that had awaited them without modern technology. In fact, if the caesarean scar was a bit crooked or developed a superficial infection as they are want to do – but easily treated with tablets – someone may even have complained!

I had read about the so called “destructive delivery” where to save the mothers life in pre-modern times, a baby stuck like this would be decapitated or dismembered to get it out. Historical obstetric text books had gruesome diagrams and drawings of the techniques and instruments used, but I had never seen them in real life. This womans situation however was of the worst possible kind, and attempting a “destructive delivery” would be more likely to kill her than achieve the desired outcome, especially in inexperienced hands.  Fortunately there was an alternative: caesarean section; but even that is a high risk solution in this environment. The risks are great enough in performing abdominal surgery on a desperately ill woman anywhere, but at a place where there is no blood bank, no anaesthetic  monitoring equipment – not even an ECG machine – and limited surgical equipment – the dangers are obvious. Furthermore, a caesarean will create a serious risk of death from uterine rupture in any subsequent pregnancies, especially if she labours miles away from help. In fact attempting such surgery under these conditions would not be acceptable or even permitted in a modern  country.  But nevertheless it was her safest option, indeed her only option. The family was called and discussions took place between them and the midwife about what needed to be done, and I saw them all rummaging through their ragged filthy clothes and handing equally filthy money over – there are charges for all obstetric services – but after a while, voices seemed to be raised and nothing was being done for the mother – “whats the problem? “ I asked. “They wont pay” I was told “They cant afford” So how much did they have I asked “40 Birr “ was the reply – about $3 between them – and they needed another $8 (130 birr) but it was easy to believe, looking at them, that they had nothing else.

The argument continued a few more minutes but no more cash was forthcoming – so I interrupted “lets get her to theatre and I will settle their account myself in the morning”  I had hesitated because I didn’t want to undermine the midwife or the way the system worked – but on the other hand I thought $8  was nothing to me  – two coffees are sometimes more and we order them without a seconds thought. The woman was dying……

So I did my first Caesar in Africa, and delivered a dead baby from a nearly dead mother. We managed to disimpact the baby from the pelvis without causing any further damage and the operation was uneventful.  The urine draining from her bladder before the operation looked like pure blood, such was the trauma the bladder had undergone during the labour. Hopefully that damage will repair itself but only time will tell : if not, before too long a hole will develop and she will dribble urine  and be constantly wet and smelly.   The baby was dropped into a big old cardboard box and forgotten about till I went to find it and later, it was incinerated with all the other hospital waste.

Am I wearing her pants or has she got my top?

 It had been a confronting and emotional experience for me, and stressful, but everyone in the hospital was tremendously helpful and supportive. I stumbled back through the tunnel of grass now wet with heavy dew and crept back into bed at about 5 am. I just felt glad that at least the mother would survive. Or so I hoped.