Sunday, August 5, 2012
Many exciting things have happened to me here in Uganda, but the evening of July 25th is by far the most memorable. My colleague Kaitlin and I set off for Gulu Referral Hospital around 8:30 pm to spend the entire night in the maternity ward. A shift change was underway as we arrived, so we were in time to meet the two midwives who would be the only staff present for the shift. The midwives were very welcoming and knowledgeable, making a smooth transition for two students feeling a little out of their depth. Shortly after our arrival one midwife went to nap, we learned this was protocol for the graveyard shift. One midwife naps for half the night while the other works, then they switch.
The night swiftly became a blur of examinations and deliveries. All said and done Kaitlin and I witnessed, and at some points helped, 10 children into the world. We also were privileged enough to experience fetal heart monitoring, dilatation techniques, an episiotomy, and a cesarean section. While you may be getting the picture, I would like to take you through a Ugandan mother’s complete experience from arriving at the hospital to leaving with her child.
Pregnant women in Uganda are required to have an antenatal card, called a Mothers Passport, containing proof that a physician has seen them throughout their pregnancy. If the woman does not possess this signed card she is not admitted into the hospital and will be asked to leave, even if she has no where else to go. This is a problem for women living in rural areas several miles away from town because transportation is potentially dangerous and costly for a pregnant laboring woman. This is why Traditional Birth Attendants (TBAs) are currently utilized as many Ugandans still live outside the country’s main cities. A government sponsored newspaper called the New Vision ran an article directly addressing the fact that TBAs should not be outlawed until there is adequate staff to replace them in the outlying medical centers. Though realistically these medical centers are too few and too far for most mothers in labor to reach, not to mention mothers with problematic pregnancies. So while the article’s message is correct, even with adequate staff I still foresee many Ugandan mothers using a TBA in the village to assist her during birth.
Once the mother presents her antenatal card to the midwife she is given a vaginal exam to ascertain the centimeters she is dilated. If the woman is found to be in the first stage, which is 1-5 centimeters, she is told to walk around and wait outside the building or in the hall. Due to the limited space in the ward mothers and their attendants spend most of their time sitting under a tree outside the building during the day and sleeping in the hallway at night. If the woman is in the second stage, 6-9 centimeters, she is then permitted in the delivery room. Once in second stage the woman and her attendant (family member or friend) give the nursing staff all the required medical items a woman is mandated to bring with her. This sometimes is all packaged together in what is called a Maama Kit, which includes: a plastic sheet, soap, surgical gloves, cotton wool, cord ties, safety razor blade, and a new child growth and postnatal clinic card. This pre-packaged kit can be obtained in the local drug stores but is rarely seen because of the cost; most women bring these items individually.
The mother or attendant then takes out the plastic sheet and lays it on one of the seven metal slabs that are used as birthing beds. All beds are in a row with sheets blocking the view from the end of the beds but essentially there is no privacy, the mothers see each other give birth and anyone walking into the maternity ward can see plainly what is transpiring. Women usually labor from four hours up to two days, quite a difference from American obstetrics where women are barely allowed to labor past six hours before drugs such as petocin are administered to speed up the process. Once the baby is born, which is referred to as the 3rd stage of the birthing process, the eyes are wiped and the cord is cut with a razor blade. The majority of children have their passages suctioned to ensure they are breathing properly then are weighed and wrapped. The mother is then given pitocin to restart contractions that help pass the afterbirth. What I found odd about this practice is the midwife, who directly after giving the injection, begins to wrap the cord around a pair of clamps and pulls the afterbirth out by force. It seems that the medicine does not even take effect before the amniotic sac is extracted manually. I believe this may have to do with the limit of beds in the ward and the time sensitive situation of other women waiting in the hall.
Once the afterbirth is procured and all is well with the baby the mother gets up (with no help I might add), gets dressed, and walks to the post-natal ward down the hall where she will be monitored for twenty-four hours before she is free to go. I also found this to be in stark opposition to the way the majority of Americans treat post birth mothers, who after two days in the hospital are still not allowed to walk to their cars, but rather are made to use a wheel chair.
The free services at Gulu Referral Hospital are as different from westernized obstetrical practices as you can possibly imagine, but they have given me a new appreciation for what a woman’s body is capable of. It has shown me that some western practices are superfluous while others are critical to a mother and child’s wellbeing.