Joy Where We Least Expect It

My past few blog entries have been less than uplifting. The experiences I described were difficult things to be even the smallest part of and difficult things to put into appropriate words. While I want to describe and examine the circumstances and consequences of underdevelopment in Atiak, I do not want to forget the other side of life. I spend a lot of time trying to battle against the stereotypes of the African continent (disease, poverty, death, uncivilized war, etc.) and I do not want this blog to contribute further to the stereotypes without also covering the good. After all, it is the good rather than the bad that brought me back to this region of the world.

I work with incredible people who have literally lived through hell on earth. Experiencing war and tragedy in the way that the people of Atiak have can break people – turn them cold or numb. The same can be said of other tragedies that happen both in Atiak and everywhere else in the world – losing a child, contracting HIV, being abused or killed based on race or ethnicity, being too poor to eat, the list goes on. Yet, while the people I have met here have every reason to resent the circumstances of their history, to be angry or vengeful, they are anything but. There is a resiliency among the people of Atiak that both humbles me and restores my faith in humanity when I’m being cynical. I see the resiliency and the vibrance each day.

I have mentioned in a previous post that I share a room with a woman my age named Nighty. The Lord’s Resistance Army abducted her when she was about 12 years old and kept her for at least a year as a rebel leader’s wife. Since Nighty’s escape she has mothered four children and been left by her husband who decided he didn’t want the responsibility of fatherhood. If you met Nighty on the streets of the US you would never guess that she has been through such hardship. She fills so many roles as a young woman – mother, daughter, sister, cook, seamstress, translator, friend. One role she has never caved to is the role of the victim. Nighty works hard. She sends money home for her children’s school fees. We stay up late at night and laugh about stupid things the way I do with my friends everywhere else in the world. She patiently attempts to teach me Acholi (I’m truly terrible at this language!). She hugs my when I’m homesick or just because. We dance in the kitchen when Pasca, the other cook, breaks out in Acholi song. We run errands in town and occasionally drink too much wine with the other members of staff once everyone’s children have gone to sleep. Nighty appears to have moved past her personal history to such an extent that it actually shocks me. Sure, she worries about things – when she’ll see her other children next (they live with Nighty’s mother in a different village a few hours from here)  and money – but Nighty is a beautiful and grateful individual when life has given her every reason not to be.

Pasca lives in the center of town about 2 miles from Earth Birth and rides her bike to work every morning. She is a widowed mother of two children . Her husband died due to issues related to being HIV+ after first passing the virus to Pasca. She also lived in Atiak through the worst of the war. Much like Nighty, you would never guess that those are the circumstances of Pasca’s past and present. She speaks maybe 30 words of English, which also happens to be the level of my vocabulary in Acholi, and yet we have been able to become good friends while disregarding a language barrier. She sings traditional Acholi songs and makes me dance around the kitchen with her. She showed me her children’s report cards with a proud smile on her face. Actually, Pasca always seems to be smiling. This weekend Pasca invited Nighty, Christine (another amazing woman who used to work for Earth Birth, but has since moved back to Gulu), and me to her home in the center of town and prepared lunch for us. She slaughtered one of her chickens for us, prepared rice and beans, passion fruit juice, showed us her garden, her hut, her family photos, and welcomed all of us with the same level of happiness that she does each day at work. Pasca is part of a local cooperative of women who make beads and jewelry and we’re working as partners to expand the project and sell the product. When the cooking is done for the afternoon, we’ll often sit outside the kitchen and make beads from recycled paper with Nighty and Esther, one of the local birth attendants who is currently a student at Earth Birth. It’s a simple activity, but it’s one of my favorite things to do here thanks to the company of these women and the friendships I’ve been able to form with them.

When it comes to spirit, Nighty and Pasca are not out of the ordinary. I have befriended several of the local birth attendants who have the same liveliness seeping from their pours. They share with me stories of their children, they sing and dance, teach me about their culture and their traditions, and they do so with pride. The history of this area, the high mortality rates, the poverty – these circumstances all attempt to turn these people into statistics, into people to pity. In reality, these are people with spirit and with hope. Be inspired by their resiliency before pitying the circumstances in which they live. I believe it will make working together to change those circumstances far easier.

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Bad Things Come in Threes

There’s a saying that bad things come in three and the past 2 weeks have taken this saying to heart. Since the infant death I wrote about earlier this month the midwives at Earth Birth have lost another baby and had to resuscitate another – whether or not that child will make it has yet to be determined, but if he does he will almost certainly have suffered from brain damage.

The second death happened earlier this week. An 18-year-old girl, pregnant with her first child, suffered through more than 36 hours of painful labor. She was so tiny in stature that it took her five hours to deliver the child. I left at this point when it became clear that the heart tones of the baby were dangerously low. When I woke up the next morning Rachel informed me that the baby boy had never breathed on his own. She and Olivia spent over two hours trying to resuscitate the baby, but nothing worked. The baby was not going to breathe on his own. The mother, referred to affectionately as Little Mama, is grief stricken and staying at the clinic for a few more days to handle the grief with more support than she will get from her husband at home – who, by the way, has been nowhere to be seen throughout the entire ordeal. While I’m glad I was spared the sight of the resuscitation, I still felt very much liked I had been punched in the stomach when Rachel told me what had happened. I went to bed fully expecting that the baby’s heart tones would regulate once the difficult labor was over – which I have seen happen in previous births here. I went to bed expecting to go see Little Mama in the clinic the next day, breastfeeding a baby.

Yesterday was the third, and hopefully the last, bad birth experience here. Another first time mother had been in labor for hours. I finished up whatever I had been working on in the kitchen and went down to the clinic to check the progress. When I pulled back the curtain to the delivery room I hadn’t known that the baby had already been born and that, like Little Mama’s baby, could not breathe on his own. A small, silent baby boy lay on his mother’s chest while Olivia went through the resuscitation process. It took me a minute to fully process what was happening, but left as soon as I figured it out. Olivia came to check on me later and told me that the baby had started breathing on his own, but it was touch and go from here. He had been deprived of oxygen for so long during delivery that if he does make it there is a distinct probability that he will have brain damage. Rachel transported the mother and baby to the hospital in Gulu yesterday afternoon, but I haven’t gotten the sense that there is much hope for him.

In the midst of all of these difficulties and losses, there has been one birth that has kept me marginally sane out here. On Saturday, a mother gave birth to her 4th baby – a girl, born breech and six weeks early. She weighs just 2kg! She was born feet first and experienced a lot of difficulty breathing in her first few hours, but she’s made such unbelievable strides as a premature baby born in a difficult setting. She needs to stay at the clinic until she puts on more weight, but she seems to be in the clear. After the past couple weeks here, we need success stories like this.

A 1993 Land Cruiser is the Only Way Out

In a community as remote as Atiak, the few resources accessible here are often a laboring woman’s only lifeline. I have ridden along on labor calls that have taken an hour or more down dirt roads, around potholes that could swallow a person whole, and through ditches that have taken down massive trucks with one poorly planned maneuver on the part of the driver.

Earth Birth is fortunate enough to have a car (the only one in the community) that operates as an ambulance, which enables the organization to reach marginalized women and families who would otherwise be left to decide between walking to the clinic or delivering alone. The car, a 1993 Land Cruiser complete with a Boyz II Men cassette tape, may actually be some sort of time travel machine back to the end of the 20th Century, but here in rural Atiak it is a modern luxury for laboring women and has already saved numerous lives. In fact, the vehicle may have saved a life just this morning. We received a call that a woman was in labor in one of the surrounding villages. When our driver and Nighty arrived, the woman was hemorrhaging on the roadside. The baby had not been delivered, but the placenta had detached and was blocking the cervix. Our driver and Nighty were able to rush her to the clinic where the midwives determined that there were no fetal heart tones and that the woman needed to be transferred to the nearest hospital – 2 hours away in Gulu – in order to stop the excessive bleeding and deliver the baby in a way that could at least save the mother’s life. A midwife helped the woman into the Land Cruiser and will work towards managing the bleeding while on the drive to the hospital. Hemorrhaging is one of the leading preventable causes of maternal mortality in the developing world and without the Earth Birth vehicle it is likely that a young woman would have contributed to that statistic this morning. Now there is at least hope. Hopefully, I’ll be ale to update the blog with her condition later this evening.

The car, while necessary, is expensive. Between fuel and maintenance it costs Earth Birth approximately $10,000 per year to upkeep the vehicle. The co-founders are currently looking for a funder and I promised to get the word out through this blog. If you or anyone you know can contribute towards this essential resource please send Rachel an email at rachel@earth-birth.com or visit the website:
http://www.earth-birth.com/get-involved/give

Thanks again to all of you for your emotional support this past week!

A Difficult Personal Narrative (warning: somewhat disturbing)

Last night around sundown a woman in labor arrived at the clinic. She had been in for a prenatal appointment two days prior and everything had seemed fine. Heartbeat was strong. The baby was moving. It was the 23-year-old woman’s 3rd pregnancy and all signs pointed to a healthy, uncomplicated labor. All that considered, I was surprised when Rachel pulled me aside and said she couldn’t find the heartbeat.

After several hours in labor progress was minimal. Rachel and the TBAs on duty still could not locate a heartbeat and the young woman was struggling to push. I couldn’t blame her. I was sitting in the delivery room, helping to hold the woman up in a squatting position to make pushing easier and I just kept thinking to myself that I couldn’t believe this woman was knowingly and calmly going through hell to deliver what she knew would be a dead baby.

A few hours into this whole ordeal Rachel would still periodically check for a fetal heartbeat. At one point, it sounded like she had found one. Rachel was doing everything in her power to help the mother get the baby out, but he was presenting shoulder first – impossible to deliver without a c-section. Earth Birth is fortunate enough to have a car that can operate as an ambulance, so Rachel had our driver and one of the TBAs take the woman to the hospital (two hours away) for the procedure and continued with a new sense of hope for mama and baby.

Not ten minutes later the car pulled back up to the clinic. As the woman exited the car with the help of the midwives I saw her dress covered in blood and balled up, clearly carrying the baby. The horrible roads and maybe the stress of such a traumatic labor had forced the baby out. His skull bones had not developed, but he had probably been alive until the point at which heavy labor began, explaining the clear heartbeat at the prenatal appointment earlier this week. Once labor began the contracting uterus likely crushed the baby’s head. When they unwrapped the baby I didn’t even know what I was looking at, but I did know that I felt like passing out.

A few moments later the woman birthed the placenta – it was about 1/4 of the size it should have been. Much like the birth last week with respiratory distress, but far more extreme, this woman was likely unable to eat as much as any person needs in order to properly sustain themselves, let alone a pregnant woman. The small placenta and the resulting lack of nutrients caused issues in fetal development. Tests weren’t run, but it’s too easy for me to assume that the baby may have developed skull bones if the mother could have eaten properly.

It was a difficult experience for me to go through – the first time I had seen anything like it and in a part of the world far removed from my support systems in the US and London. I’m sad, of course, and I hope I never see anything like that again, but I’m also angry and struggling to process the entire ordeal. It’s easy to blame the circumstances – a poor woman in a poor community without adequate food resources gives birth to a dead child with a crushed head? I mean, really, how do I not blame the circumstances? It was also so hard to watch the mother. Her husband was nowhere in sight – he had sent his younger brother instead. Throughout the entire delivery this woman, my age, was so strong. We walked the room together to speed up labor, she pushed without complaint, she was so strong throughout the entire thing. It was when we unwrapped the baby that I almost had to leave, just to avoid bearing witness to the mother’s reaction. My heart completely melted for her and there is nothing anyone can do to make this easy for her.

I’m trying to turn the experience into a way to motivate me. Some moments it works and other moments I can’t think, but it’s been less than 24 hours so I suppose I need to give it time, experience some good, happy births and move forward.

Thanks for reading such a personal and unfortunate post and thanks to those of you who were able to support me via the crappy internet connection yesterday and today.

A Few Thoughts on Reproductive and Sexual Health

Wednesday evening, a young woman around my age delivered a baby boy. I had initially had high hopes for this particular birth. It was her third child, there had been no difficulties during the pregnancy that we knew of, and I was actually able to be helpful during the delivery (nothing medical, of course, but still exciting). Yet, when the baby was born it had great difficulty breathing. Rachel and Olivia suctioned his lungs and nose, but the respiratory distress continued for quite some time. His cry was weak, Rachel could feel that his lungs were not inflating, and he was very clearly struggling. As Olivia administered a homeopathic, Rachel inspected the placenta, indicating that portions of it had calcified in the womb, meaning that those portions had stopped working. The reason? Malnutrition. With two children and a husband at home in this very poor region of the country, a pregnant woman was unable to eat, jeopardizing both her health and her unborn baby’s. The homeopathic worked, by the way, and the baby and mother were discharged three days later, but we can’t know for sure what the future repercussions of the respiratory distress and calcified placenta will be.

Later that night, a 15-year-old girl arrived at the clinic to deliver her first baby. The father, nowhere to be seen, is 16-years-old. What were all of you doing at 15 and 16? She had a long, difficult labor through the night. The baby’s heart rate was dangerously low and by the next morning Olivia and Rachel were pushing to get the baby out as soon as possible. After difficulties, a baby girl was born, weighing in at 2kg. Her heart rate steadied and both mama and baby spent the day recovering from labor. The next day, the father’s mother, who is 32-years-old, arrived to take the girls home. I sat in on a conversation Olivia had with the girl and grandmother about family planning and safe sexual health. Olivia told the grandmother that she needed to speak with her son about the importance of family planning, how to avoid pregnancy, and how to be a father. The woman’s response? He is too young to have that conversation! So, a 16-year-old is old enough to have sex, old enough to get someone pregnant, and old enough to be a biological father, but he is not old enough to learn about abstinence, to learn how to use a condom, to learn how to space pregnancies, or to learn why these things are important?

Conversations like these happen frequently at the clinic and the evidence is all over the community. At the district health office expired condoms meant to be given out for free and stacks of educational brochures forgotten in corners. I have met women with as many as eight children and barely enough resources to sustain the whole family. Some women plan to have many children, but there are plenty of women who do not and who simply are not in an educated position to avoid pregnancy. The repercussions of this, as I saw last week, may be difficulties in labor or dangerously stretched resources at home, but this lack of family planning also contributes to maternal and neonatal mortality in a region where the provision of healthcare is weak.

In one of my modules at LSE we spent a couple classes on why people have large numbers of children and why the fertility rates are higher in Africa than elsewhere in the world. Some people have argued that it’s an economic decision. The more children you have the more people you have to farm and to contribute financially to the family in the long run. People may also have more children because they anticipate that some will die, which is often the case in poor parts of sub-Saharan Africa. I think large families and motherhood at such a young age may simply be embedded in the culture. I have been asked by several TBAs here why I don’t have children yet, how many will I have when I do? When my response is “maybe two, but I don’t really know yet,” I am greeted with shock. “You should have at least four!” they say, incredulously. But why? A part of why people may have large families here is that they are expected to at a cultural level. While I am here to immerse myself as much as a white American can in the culture of Atiak, Uganda, and while throughout my career in international development I will focus on respecting and participating in culture, some cultural expectations are dangerous. Having six children at 23 in this environment is not the best for mother or child, nor is becoming a mother at 15.

In the past week or so I started looking into some organizations that focus on reproductive health and family planning, thinking that I might like to shift my focus or include those aspects in what I hope to do with maternal and child health in the future. These issues need to be a significant focus in the field of international development.  I think that with greater importance placed on reproductive health and family planning we will see healthier families, more educated people, and, hopefully, an empowered gender identity for women.

“What exactly are you doing there?”

I’ve been talking about Earth Birth for months in anticipation of my trip here, but hardly knew what I was getting myself into. At the most basic level, Earth Birth is a maternity center that provides services to women in a community deeply traumatized by war. The organization seeks to foster a safe and culturally appropriate environment for women and their babies throughout pregnancy childbirth, and the postpartum period. Earth Birth also functions as a school, pairing senior midwives with student TBAs from the local villages. Classes take place weekly here to go over skills necessary for ensuring safe delivery.

A lot of people have asked me why women don’t prefer to give birth with professionals who have been formally, medically educated and in a hospital. That isn’t a safe or realistic option in Uganda, to say the very least. The nearest hospital is over two hours away via car and if a woman were to make it there she would be faced with a severe shortage of staff, beds, and equipment. Rachel, one of the midwives and co-founder of Earth Birth used to work at the hospital in Gulu and it was the circumstances there that inspired her to create this maternity center. She has told me stories of women laboring in the hallways, getting a bed only when it is time to push, and being discharged just 10 minutes after delivery. In spite of these truths, the Ugandan Ministry of Health has issued a ban against training TBAs and traditional midwives, labeling them as incapable of learning and responsible for Uganda’s high maternal mortality ratio. TBAs, however, remain an essential resource in community health. They have continued to practice as long as there is a demand for them and at over two hours from the nearest hospital where the risk of death is even greater, you can be damn sure the demand is still high in Atiak, Uganda. TBAs and traditional midwives offer essential healthcare where there would otherwise be none and through Earth Birth they are able to do so safely.

My role at Earth Birth will turn out to be quite fluid, from what I can tell after just five days here. In exchange for food, housing, and the experience I will gain here, I’ve committed to three months of working here in what Olivia has called a “managerial position.” I’ve been assigned three main projects that I am trying to get off the ground and running before heading back to the States by Thanksgiving!

1. Olivia and Rachel want as many of the supplies as possible to be sustained by the local economy or through local craft. I am hoping to get sewing, beading, and gardening projects started amongst the women who use Earth Birth services. Vegetables from the garden can be sold in the local market while sewn and beaded projects will be sold in the US through partnerships with fair trade stores – at least that’s the plan I envision for now!

2. Right now, all of the protocols for pregnancy, childbirth, and the postpartum period are written in English, which is useless in a community where most women do not speak English, let alone read it. I am establishing a team of TBAs who do speak English and together we are going to create a protocol manual that uses Luo (the local language) and images for the women who are fully illiterate, but still a crucial resource to their communities.

3. The last major project  is the one I am most excited about. As I mentioned above, the Ugandan Ministry of Health has banned TBAs and their practice, but based on evidence I referenced and further evidence in my dissertation (you can ask, if you really want to read it) this is a less than ideal policy decision. It is impractical to expect TBAs not to practice when the need for them is still so great. I’ll be using my research and Earth Birth statistics to create a report indicating the success of this program and that these women have had on the community in hopes of encouraging the Ministry of Health to consider a more incorporated role for TBAs in the health system.

That’s all for now, but feedback and comments are always appreciated!