COTW: Continuity

 by Rachel

When we moved to Africa to begin practicing medicine, there were several things that I knew I was giving up...some not so hard to say goodbye to (electronic medical records and litigation!), and some, like a wide range of medicines and technology and support services, more so.  One sad thing to give up was the idea of patient continuity.  I really enjoyed the chance to develop a relationship with a woman during the course of her pregnancy and deliver her baby and even follow up in the subsequent years (of course, residency was only four years long, but I still had some special patients during that time).  Here in Burundi, continuity is a challenge.  I function primarily as a consultant--I don't do normal pregnancy surveillance and almost never do deliveries except for C-sections.  Women come with a problem, I give advice and treatment, and then almost never see them again.  When I do, it's a rare gift.

When we returned from the US in 2016, there was a patient waiting for me named Odette.  A colleague had done an ultrasound in my absence and found what looked like an abnormal pregnancy.  I repeated the ultrasound and found a normally developing pregnancy, her first, but also a huge fibroid, more than 10 centimeters, filling up the lower portion of her uterus.  She came back many times in the following seven months for ultrasounds.  She rarely spoke but her husband and I conversed often in French.  In my head, I continuously ran through all of the potential complications that were awaiting her.  But lo and behold, she arrived at term without incident and we delivered a healthy baby boy by C/S.  I asked her to come back 6-8 months later and we removed the fibroid.  I thought that would be the end of the story and our relationship.

But then again she returned, now in the spring of 2018, with another pregnancy.  Her uterus looked perfect, but given the two surgeries, we scheduled another C/S and I performed it just before a scheduled six month in the US.  And now, just a few weeks ago, she came with her third pregnancy, already in the final weeks.  I performed a C/S on Tuesday and delivered her third and final baby.  It was oddly touching to me to be able to safely bring all three of her children into the world.  I don't know if she ever realized how remarkable that was.  She and her husband don't even live in our health district...they come from another province in the country.  So many women never show up for their scheduled surgeries, or labor begins too early and they deliver elsewhere.  I take vacations occasionally (!) and spend six months out of the country every few years. But everything lined up perfectly in this case.  

I didn't take any pictures...I always feel oddly awkward about taking pictures of my patients...but I will certainly remember the privilege given to me by Odette and her family. It's a small but tangible reminder of God's provision and a giving back gift of grace to me, even of the small things I feel like I've given up for His service.  

Zigama Mama

Zigama Mama logo, designed by Carlan

by Rachel

I've always been interested in the idea of public health.  People have likened the idea of medicine in the developing world (or elsewhere) to pulling drowning people of of a raging river.  Public health is going upstream to figure out why so many people are falling into the river in the first place.  Of course, if all your time is spent saving the drowning, it's pretty hard to find the time to pull yourself away to take a walk upstream.  Important and necessary, but challenging to prioritize none the less.

After six years here, Eric and I decided to take that walk.  Ever since the first months here at Kibuye, I have been noticing a huge amount of uterine rupture (UR) cases.  They are very rare in the US, but we have about 20 cases per year here (Side note for the medical folks: I looked at cases of UR from 2015-2017 and found 55, which is over 1% of our deliveries. !!??  Only about 50% of there are on uteri with previous scar.  So we have a huge amount of UR on unscarred uteri, which is pretty rare in the medical literature.  Harder to prevent for sure...).  A big risk factor for UR is labor after a previous Cesarean section.  Everyone in the health community "knows" this, but given broken systems and difficulty in education, many women who are at risk for UR continue to labor at home, in their villages, way after their due dates, instead of receiving a scheduled C-section or coming in to the hospital to deliver under surveillance.  Some show up with three previous C-sections, in labor, and don't even know their due date.  If only we could find a way to get these ladies to come in sooner, to decide if a C-section is the best decision, and to choose a date for that C-section, maybe we could prevent some of these cases of UR.  At the very least, we can decrease complication rates of infection, hemorrhage, fetal distress, etc, which are all higher in women with emergent vs scheduled C-sections.

Enter, Zigama Mama.  This is technically Kirundi for "protect the mother."  Our Burundian friends say that's not exactly the way they would say it...but we decided to use the phrase anyway given its catchy nature! :)  Our hospital is the referral site for 17 health centers in our district.  Any woman needing a C/S or increased surveillance would get sent from them to us, which also explains why our C/S rate is about 30% of our deliveries each year (instead of the national average of 6%).  The idea of Zigama Mama was to look at all of our C/S data from the health centers for one year, then do a training session for the nurses at the health centers.  The intervention is simple:  every woman with a previous C/S, even one, gets identified by the nurses, written into a register, and then she gets a "coupon" for a free ultrasound at Kibuye.  While ultrasounds are recommended in pregnancy, they are cash pay ($5) and most women can't afford them.  So, the free ultrasound is the incentive to come to Kibuye, where I can confirm their due date and decide if a C/S is indicated or not.  If yes, I schedule it.  If no, I encourage the women to come to the hospital (not the health center) for monitoring as soon as labor starts.  That's it.  We'll look over the next year to see if our rates of emergent C/S and UR decrease.

Training on Postpartum Hemorrhage, using resources from Laerdal Global Health

We had the initial training session last week.  Honestly, I wasn't sure how it was going to go.  Eric made up a schedule that involved a start time of 8:30.  At 8:30 on Thursday morning, only one person (out of the possible 35) was there.  However, people trickled in over the next hour and in the end, 16/17 health centers were represented!  We presented the rationale for the program, the nuts and bolts, and then had several hours to do some training for the nurses on post-partum hemorrhage and neonatal resuscitation, as well as share a meal together in the canteen.  It was great to see our Burundian doctors coming in to help out with the hands-on training programs.

We divided up into groups to practice techniques on a uterine model for treating PPH

Dr Ladislas, one of the Burundian docs on my service, also did a great job leading one of the groups

On Monday morning, I actually already had four ladies show up with their Zigama Mama coupons!  I'm excited to see how this intervention can have a positive impact on the health of women in our district.  There remain so many barriers to access to care, but hopefully, little by little, we can chip away at them.

The Zigama Mama ultrasound coupon

Baby Moses & Mama Clairia

By Susan

About 5 months ago, a baby boy was born in a field just up the hill from our hospital. For reasons we will never know, the mother left the baby there and disappeared. Thankfully, a hospital worker heard crying, and found the baby very shortly after, and quickly brought him to the hospital.  Our pediatrician checked him over and miraculously he appeared to be healthy. Due to the risk of being born and left in a banana field, he was put on a course of IV antibiotics to make sure he didn’t contract an infection. 

Like all the patients at Kibuye Hope Hospital, this baby was required to have a caretaker. Someone to be with the patient at all times, to help with their care.  Since this little baby had no one to take care of him, some of the other mothers in the NICU pitched in to help. Despite needing to care for their own premature babies, they helped with his feedings and care for him for the first couple of days he was there. We knew we needed a new plan to care for this precious baby. By this time, I had started calling this sweet orphan, Baby Moses.  

Alma & Baby Moses

The book of Exodus contains a beautiful adoption story of a Hebrew woman who had a son at a time when
 the Pharaoh ordered all Hebrew male infants to be put to death.  Instead, the Hebrew mother found a basket, waterproofed it,  placed her son inside, and gently sent him down the river.  Not long after, one of the Pharaoh’s daughters caught sight of the basked and retrieved the young baby.  She eventually adopted him into the royal family and named him Moses (Exodus 2:1-10).  This is the same Moses who grew to be an important leader, a prophet, and a faithful servant of God. It's a story about a child being rescued from certain death, a story of God's providence, but also a story of the compassion and care of this Princess. 

Clairia, months into her care.

At the same time that Moses was in the NICU, there was an 8-year-old with a terrible bone infection recovering in our surgical ward.  Clairia had been in the hospital for many months at this point and had endured several painful procedures and surgeries.  I had gotten to know Clairia and her mother quite well after spending time visiting and playing with Clairia each day.  It’s common here to refer to women as “Mama “ + the name of their oldest child. I admired Mama Clairia. She was quiet, gentle, patient and faithful.  She was right next to her suffering daughter every minute of the day, holding Clairia down during painful dressing changes with tears in her eyes, and comforting her in quiet whispering and prayers.  

Finding joy in the midst of pain.

Learning how to walk again.

When I explained to Mama Clairia that we had a 2-day old baby with no one to care for him....there was not a moment of hesitation.  She said that if she could remain in the surgical ward by her daughter’s side, then she would be happy to care for Baby Moses.  Now she not only cared for her sick daughter but for a newborn.  She never complained.  She never asked for anything.  She had spent months in the hospital, away from her home, her husband and her other 4 daughters, and now cared for a newborn. Yet she was content. I have learned so much and still have so much to learn from this faithful and beautiful, strong and quiet woman.

She treated Moses like only a loving mother could. Changing him, feeding him, singing softly to him, whispering in his ear. Burundian culture has a special ceremony for the first time a baby is tied to its mothers back (where it will spend the majority of the next year!) I had the privilege of being there when Mama Clairia tied Moses on her back - caring for him as her own.

After spending 6 full months in the hospital, it was finally time for Clairia to leave our hospital and return home.  Before they left, Mama Clairia came to me and explained that she, too, was an orphan.  She told me that she believed Moses was still far too young to leave in someone else’s care, and that she really wanted to continue caring for him in her home. She told me that if she had to give him up, that her heart would break.  Moses was 3 months old when he finally left the hospital grounds for his first time ever and got to go home....his new home.  

Giving Moses his last bottle before he left the hospital

Finally going home

Every Friday I have the privilege of seeing sweet Baby Moses, as his foster mama brings him back to the hospital to collect more formula that we have been providing for him.  He is growing and thriving...and is loved.

A few weeks ago, our family ventured out one Saturday morning to find the home of Mama Clairia and Baby Moses.  Even though we took someone with us to translate who was born and raised in this area, it was still not really possible to understand directions. So we arranged to meet her at the closest road. She jumped in the back of the truck (with Moses on her back) and lead us the rest of the way.  We followed a series of small dirt paths, each getting consecutively smaller until finally, the Land Cruiser couldn’t fit anymore. We parked the truck there on the footpath, bananas on one side, coffee bushes on the other, and followed Mama Clairia to her house.

Mama Clairia's home

Their home was a small, mud-brick home, with a neatly swept dirt yard surrounded with a fence of woven sticks. We ducked through the short door, to be greeted in the one room. It was maybe the size of our girls' bedroom. But instead of housing two girls beds, their clothes, books and space to play - this room was everything. This is where the eight of them sleep, where they eat, and where the girls do their schoolwork. There is a small room off the back of the house for cooking and a little hallway that connects the two spaces, which they use to store a few hoes and small cook pots.

They gathered up enough chairs from neighbours so that we could sit in their neat, one-room house. They told us how happy they were to have Moses in their family. How the girls adored having a brother. How Papa Clairia didn't hesitate when his wife told him about the child. As we sat and visited they told us about their hope that Clairia will be able to return to school this fall, and how they hoped they could find someone to sell them milk for Moses. Like most families around here, they struggle to feed their children. They don't have luxuries like running water or electricity, and they work hard to just survive. Yet this couple was eager to extend what they had, to help care for this child who had entered the world in such dire circumstances.

Their family insisted in walking us back to the truck, and as we did Alma and Clairia ran up ahead. To see the two girls, my daughter and a  girl who had been immobile, in horrible pain, and sad for so many months, skipping down the path was a gift I can't describe. 

There are a lot of hard things here, and getting to glimpse just a little bit into the lives of Claria, her sisters, her mother and father, and her new baby brother help me to see that in a new light. Both the extent of difficulties, the depth of sorrow, the complexity of poverty - but more importantly the joy of hope, and the light of love. 

I don't know much about Egyptian princesses, but I find it hard to believe that Pharaoh's daughter had anything on this woman. Mama Clairia did not take in a child to care for in the lavish excess of a palace, but she truly sacrificed what little she had to take him in. She has no servants and attendants, and unlike Pharaoh's daughter, she doesn't send to find a woman to help care for the child. She walks all the way to our hospital every week. She cares for him. She literally carries him. 

I don't know how this story will end. In a place like Burundi, it really could go so many different ways. But what I do know is this woman, who grew up an orphan, who now lavishes care and love on six children has taught me so much. 

What sacrificial love it.

What true care for others looks like. 

What contentment can actually look like. 

Paternalism

by Rachel

“We want autonomy for ourselves and safety for those we love.”  —Atul Gawande

 I’ve had a lot of bad outcomes lately.  I guess things tend to run in spurts…bad things come in threes, or multiple patients come in with the same diagnosis after months of not seeing that diagnosis at all.  Lately, I’ve been thinking about multiparity, or really, grand-multiparity.  For the non medical folks, “parity” refers to the number of times a woman has given birth.  When that number reaches 5, she falls into the category of “grand.”  When I was doing my training in residency, it often seemed that the first pregnancy was “the worst."  Meaning, if you were going to get a complication, it would more often happen with the first one.  Walking in to Labor and Delivery and seeing a whole unit full of “nullips” (first time delivery) meant a long day and/or night of unknowns while we watched and managed and hoped that a C-section wouldn’t be necessary.  A unit full of women who were on their second or third deliveries was much more upbeat, fast paced, certain.  Of course, it wasn’t very common to have a unit full of women on their 5th, 6th, or 7th deliveries.

Burundi is very fertile country, in more ways than one!  The average woman will have 6 babies in her lifetime.  My clinic is flooded with women who can’t conceive, so it stands to reason that for every one of those women, there’s another on her 10th pregnancy.  And, soberingly, a woman stands around a 1:30 chance of dying due to a pregnancy complication during her lifetime (UNICEF statistics from 2010).  It also stands to reason that the MORE pregnancies you have, the more risk you expose yourself to.  I had an attending who liked to say that getting pregnant was the most dangerous thing a woman could do with her life.  OK, I think that’s a bit extreme.  But oftentimes, especially in the US with a well developed medical system, we forget about the potential risks of pregnancy and childbirth, especially because the risks seem so minimum in comparison to what you get out of the deal.  Even with all my training and knowledge of the complications of pregnancy, Eric and I decided to go through the process three times! (And let me tell you, I do NOT take the fact that we had three uncomplicated deliveries and three healthy kids for granted).

So, back to my bad outcomes.  I had two maternal deaths in March with almost identical stories, women who should have had a straightforward delivery.  Two previously healthy women, both on their 7th pregnancies, both with 6 living children, who presented to another hospital after prolonged labor.  Both had a ruptured uterus (where the uterus basically tears open because it’s been working so hard to get the baby out) and a dead baby.  Both received surgery to attempt repair, which failed, and were transferred to me for “better management”.  Both arrived in shock.  Both received hysterectomies to try and stop the bleeding.  Both died within 12 hours of arrival due to coagulopathy.  

I felt very powerless in the process.  I felt like my best efforts were not good enough.  And I felt regret for a system that tries but isn’t good enough to save these women and ensure their children grow up with a mother.  And finally…I felt myself wishing these ladies had just stopped having babies.  If only they had decided 5, or even 6, was the perfect number of children.  If only.

These are not the first two women who have died after similar circumstances.  In fact, after doing some research I found that it’s shockingly common in the developing world to develop a ruptured uterus because of long labors or limited access to care.  And experiences like this color my opinions and decision making.  If it can happen to those two women, why not others?  

So I keep advocating for better care, and better birth control.  I perform a C-section for a woman…it’s actually her 5th, and she has two living children.  The surgery is a mess and takes forever, due to layers upon layers of scar tissue.  At the end I tell her that we should tie her tubes because this is getting too dangerous for her.  She refuses.  Multiple times.  I take one tube, and then the other, in my gloved fingers and think about how easy it would be to tie her tubes right now, even without her knowing.  Even without her consent.  Surely, she doesn’t have enough knowledge or experience to know how dangerous another pregnancy could be for her.  I could probably be saving her life if I tied those tubes.  Or at least, saving her from terrible complications in the hands of the next, possibly unexperienced doctor who tries to perform another C-section on her in the future.  I am the one who spent years and sweat and tears and money to receive my medical training, to be able to advise and treat…my knowledge base is far superior to her own.  

And then I think about why I am here in Burundi.  About how much I care for these women, all of whom have suffered so much at the hands of family, husbands, an incompetent medical system, life.  About how they are all fighters, and how I want what’s best for them, to empower them.  And I realize that taking away one of the only choices she has, to make a decision for her, is exactly what I’m fighting against.  And I slip the uterus back into her pelvis and close up the layers, and hope that she never gets pregnant again….but if she does, I hope, I hope, I hope that she lives through it.

I don’t know.  I doubt myself.  But I know that change does not come by taking away autonomy.  I want these women to be safe, yes.  But there are other ways to bring safety.  If only…