I start this letter with an audible sigh. This morning I am attempting to summarize a year of great learning, great teaching, and great growth, and all of this referring to ‘me’ and what I have learned, what I have been taught and how I have grown. At the feet of students, of Tanzanian health care workers, and of my Dodoma community at large, I have been greatly schooled and been more than generously blessed in the process. As is usually my experience with work in the developing world, I gain much more than I am able to give back. So this story unfolds of a place where great strides have been made, rethinking maternal child mortality, and especially in rethinking the delivery system currently in place to care for families.
Early in my term of service I attended a morbidity and mortality review. It was brutal for those on the ‘kitti moto’ (hot seat), giving reports of obstructed labors, of ruptured uteri, of fresh stillbirths, of maternal deaths from postpartum hemorrhage, from eclampsia, from pyelonephritis sepsis and from a high spinal block that knocked out the mother’s respiratory drive. I literally shudder when I recall this first straight-forward review of what kills mothers and babies in the Dodoma Region of Tanzania. Now I have my own eye-witness scenarios to contemplate, about how circumstances contribute to delays and poor outcomes despite level-best efforts. Tanzania is a country where there is tremendous effort to improve both maternal and infant mortality; the road forward includes all of us who have become rafiki (friends) of this place and those we serve.
I relate to you these stories as a way of preparation for others who will serve alongside their Tanzanian colleagues, in an effort to help not only with preparation for clinical work but in brainstorming best ways to come alongside our partners’ in-country. Each circumstance I relate, describes preventable deaths, ones that wake me up at night wondering how the story might have ended differently.
One morning, when MSc Pediatric students were immersed in an intensive didactic course, I went on my own to the pediatric ward at the regional referral hospital, knowing how desperately short of help this unit is, chronically. The back ward room, on the right is usually where the sickest of babies and children are housed. To the left of the ward is where twenty or more severe acute malnutrition cases, receive care, alongside those convalescing from burns and other traumas. On this day in particular my eyes went directly to a newborn baby, with Bibi (grandmother) at his side. No mother was near, which is particularly unusual, as Tanzanian babies are symbiotic with their mothers. The mother-child dyad is a testament to how breastfeeding keeps generations alive in this part of the world. Seeing no mother, I went directly to this bedside, and found a hypothermic baby; checked axillary temperature from my ‘fanny pack’ thermometer, reading 34 degrees Centigrade. The grandmother was sitting on the bed, and in my very poor Kiswahili I gathered that this fine nicely grown boy was a ‘twin’ (mapacha) with his mother and twin sister on the surgical ward, recovering from cesarean birth on Ward 17. Urgently I grabbed a medicine cup, gave the baby a squirt of glucose orally, double-wrapped him with dry blankets and ran with the Bibi to the surgical ward to identify ‘the mother/her daughter’ and to express breastmilk. It is not often that you see people running at the hospital, but in 7 minutes flat the Bibi and I had collected 20 cc of breastmilk and returned to the ward to feed the baby and start Kangaroo Mother Care (KMC), or in this instance, Kangaroo Grandmother Care. When we arrived back to the bedside, the baby boy was dead. I cannot tell you the ways I have reworked this story. Would there have been a better sequence for actions?
These are the scenarios that wake me at night. What if there had been a warmer available? Should I have strapped him skin to skin with me, while going in search of the mother? Should I have taken the time to start an IV instead of going for the breast milk route? Then I rework the triaging of the family members. How could someone sit at the bedside of a cold newborn twin and not offer their warmth to a little one? What is the cost to our humanity of losing even one perfectly grown baby due to the lack of human body heat and breastmilk? How can life be measured? What is the cost to our world when we have seven degrees of separation and a baby needlessly dies?
This was a particularly difficult case for me, considering my own twins, who were really never separated until they choose different beds and bunks as preschoolers’. The rescuing hug of twins is a well-known therapy we used as ICU nurses, and experienced mothers. Babies know this innately, one arm over the other, in a way of ‘rescuing’, warming and encouraging their twin. Anne and Laura used to sleep back to back, being both vigorous kickers, preparing no less for their future careers, pan-athletic. This case has wakened me more nights than I care to admit. I remember his sweet hair and fine features, reworking the scenario in my heart and my mind. Why was the twin separated from the other, choosing definite life for one, and not the other? This was not a case of sepsis, in a nicely grown 3.2 kg baby, who was perfect in every way, just hypothermic and hypoglycemic.
Next is a case of a 16-year-old laboring primipara who was progressing well, with a healthy fetus. During her active labor, I was monitoring that baby, checking heart tones, rubbing her back, reassuring her, ‘mtoto moyo n’zuri’, which even in poor Kiswahili reassures a mother that the baby’s heart beat is fine. And it was. What happened during her second stage is another question, one I have replayed in my memory. At the time of this young woman’s pushing phase of labor, I was attending another birth with fetal distress. The patient I was managing with two young midwives was used as a way of bringing alongside eager young providers to teach about intrauterine resuscitation. With intravenous fluids and left lateral positioning, they were able to see that a simple fluid bolus of lactated ringers, open-wide, could resuscitate a baby before birth. I explained that the pattern we were ‘hearing’ on auscultation was a nuchal cord or occult cord and the IV would be life-saving. And to these young midwives’ credit, they immediately understood what was being done. The mom received the bolus, was positioned on her left side, the baby’s heart beat responded from 90 beats to minute back to a more acceptable 120/minute, buying time until birth. When birth did occur nicely, about 15 minutes later, the mother pushed out a big baby with two nuchal cords, easily reduced with hand maneuvers. Then after ‘maneuvering’ a bit with the big shoulders, a healthy 4.4 kg baby was born! The young midwives looked at me like I had X-ray vision in order to identify nuchal cords before birth. I assured them it was just in listening to the baby, ‘they tell us when they need to be delivered’. All midwives, universally, know that slow thud of a fetal heart that calls us to deliver now. We can get babies delivered ahead of schedule in such scenarios by telling the mother of the urgency to push her hardest, by expediting second stage with vacuum or Ritgen’s. These possible ways to getting a baby out quickly are used when we know a baby needs our hands to attend to this little one urgently.
Concomitantly, in the next bed, from my peripheral vision I saw the young teen I was attending during her first stage, now pushing with an experienced midwife preparing for birth. The ‘sage’ midwife was intent on working the perineum, as the young one was grade 2 circumcised; I appreciated her efforts. However, there were no heart tones being monitored. I was becoming concerned, and nervous about this baby, 4 minutes with the head sitting on the perineum. I weighed in my mind how much of an international crisis I could cause by interfering in this birth. The midwife was my peer, in age and experience. I didn’t act and take over the case; it was something I regret to this day. When I was called by her to assist, I received a severely asphyxiated baby boy. One of the young midwives helped as we worked on him, giving him a full resuscitation. His heart and lungs responded; lucky again with the fanny pack, this time for epinephrine for the umbilical vein. ‘He’s back’, said the young midwife, and indeed the little one was with us, but he was ‘cold’. He had a good pulse, there was some increased work with breathing, but mostly he was surviving. I decided that I could plug in the oxygen source, and sacrifice the warmer’s plug for a minute. In my mind it was a good plan, alternating back and forth with the one wall plug, shared by the whole labor and delivery ward. The plan did not work. I had to choose between a plug-in for oxygen, and a plug for the warmer, but not both. It was one of the most frustrating events of my time in Tanzania. The midwives watched me for several minutes, seeing I was not able to keep the baby warm with the warmer, while needing the one available plug to sustain oxygen saturation with the concentrator. So, in the usual fashion of denial, I watched as the young ones retreated out of the ward, not wanting to witness the baby’s death. It must be helpful for a health care worker to deal with their lack of critical life-saving equipment, by refusing to witness the preventable deaths that occur so frequently under their watch.
I was alone, with this little one, cupping my hands over this feet and limbs, covering the head, breathing warmth on him, while he was receiving oxygen by nasal cannula. And for 45 minutes, back and forth choosing between warmth or oxygen, and feeling like both of us had been abandoned. Not a word was said to me when I let out a sob, feeling as if this was another preventable death. The head midwife took the baby to the light bulb bassinette on the ward, to warm the little one before taking him to his mother. I have seen workers not report to a mom that their baby did not survive. When the baby is wrapped and warm from the warmer, it is the mother who appears to have discovered that her baby is dead. Withdrawing, standing back, removing oneself from the trauma of death is probably a necessary coping mechanism here. The commonest of problems in this world of ‘too little’ for so many, is such a stark difference between the global north and the global south. It truly breaks my heart.
What woke me the next nights was the re-thinking of the little ones’ care. Could I have used the mother’s chest during resuscitation even though lengthy? She trusted me, we had developed that sweet eye to eye contact during active labor that shows when a midwife if truly ‘with woman’. Might there have been a way to extend the oxygen source from the plug in to the bedside? There was no extension cord; there was no other outlet for the warmer or oxygen. What if I had simply been an ‘interfering’ American, listening to heart tones every 5 minutes during second stage and getting that baby out, easily after 2-3 minutes on the perineum? I know maneuvers that hasten birth and save a baby’s life; could this have been a major teaching moment? I know that I cannot cope with death by denying the loss. Denial is a repertoire, a common protection for many of my Tanzanian colleagues. I suspect however that what looks like denial is really the second victim syndrome. My colleagues have neither the time nor energy to cope with their strenuous midwifery work, much less one more death that crosses their ward every few days. I do not assume that life has less value in Tanzania; I am resigned to think that it is survival that drives actions. Health care workers do not want babies who are unable to live and work and be fully functioning in this Tanzanian world. Until they see the outcomes of fast resuscitation, of expedited vaginal births and of healthy newborns from safe care, they will not trust this hopeful story. However, when they hear dangerously low fetal heart tones and witness the actions that do intrauterine resuscitation or fast delivery, then the status quo shifts. Hope is an essential part of my work here; if I have created hopeful scenarios for others during this year, every ounce of my effort would be worthwhile.
This is why the story of ‘reframing’ status quo plays such an important part of this year’s work for me. Working equal hours on the wards as in the classroom, I have been able to show students and young African colleagues best practices, concerning managing labors safely, resuscitating babies before there is asphyxia’s damage, being at the bedside of mothers. And it works. Outside of the glass window connecting the labor ward with the resuscitation room, I see a line of on-lookers, just amazed at the rapid response to one baby who needed a bit of help to breathe during the golden minute after birth. When these babies are resuscitated immediately and then can remain warm and pink, skin to skin with their mothers for warmth and breastfeeding, the pendulum swings to survival. I can detect faint smiles on my colleagues’ faces while looking on at a successful resuscitation. ‘Hope’ is what I call this look; it is an immunization against despair, a protection against giving up. Only small steps need to be taken to make huge differences.