Monday, December 24, 2007

Common Pregnancy and Birth Myths in Ghana

Eating eggs during pregnancy may cause a baby's skull to be too soft, which will cause headaches in the future.
Eating too many apples during pregnancy will cause the baby to grow too fat for birth.
Having intercourse during pregnancy may cause blindness; the belief is that semen will be deposited on the fetus' eyes and cause blindness.
Eating meat during pregnancy will cause a child to grow to be a thief.
At birth hot compresses may be applied to a baby's skull to deliberately mold the baby's skull to give it a "special" shape.
At birth hot compresses and herbal concoctions may be placed on a baby's skull to close the fontanel; it is believed that the open fontanel is caused by sickness.
Female babies are douched with warm water, sometimes hot water, because of a belief that the vulva is sore after birth.
Because women do not know how to properly position and attach babies on the breast, infants often suffer from marasmus, or protein-energy starvation; women believe that this condition is a spiritual affliction given to the baby while in utero.
Many women, even those who intend to breastfeed exclusively, believe that when a baby hiccups he or she needs water to stop the hiccups.
During labor when a mother's body is massaged the blood vessels in the baby's eyes may rupture, causing blood to collect in his or her eyes.
A common belief is that at eight months the fetus dissolves into blood and at nine months it reforms before birth. Therefore, some women believe that having an abortion at eight months is safe. This practice often results in death.
Women have expressed the belief that when they vomit during labor that they are vomiting amniotic fluid.
Many women insert herbs into the vagina to deliberately dry the natural vaginal secretions with the view that men will enjoy intercourse more; this practice increases the risk of lacerations and thereby transmission of HIV.
Some women have expressed the belief that when they use an IUD for family planning the device may travel to their heart and cause heart problems.
Women often believe that the symptoms of menopause are caused by a spiritual curse.
Some HIV-infected men will seek out sexual relations with virgins; they believe that HIV can be cured through intercourse with a virgin.
Men often believe that the gender of their baby is determined by the mother, which causes conflict when his desires are not met.
Some women believe that their fertile vaginal mucous secretions, which appear during ovulation, are a sign of infection and therefore make a conscious effort to wash and dry away the secretions. This causes some women to have difficulty conceiving.

Wednesday, December 12, 2007


Senegal part 2

Delivering babies in Senegal is very different from birthing at home, and from being in an American hospital, even the crappy ones like Kaiser Sunnyside (I thought it seemed dirty. I had no idea). There were three different clinics that we worked at. One was far from Mboro, and I actually didn't catch any babies there. The delivery room was smaller than most master bath rooms. It had one of the "typical" delivery tables---they are short and sturdy, mainly metal, nothing moves or stretches, or is remotely comfortable about them, I imagine not even to a cadaver. For the most part women give birth on their backs, like we did in the 1950's (and honestly more recently than that) only they don't put their legs up in stirrups. At the main clinic, there were two delivery tables and one, slightly more comfortable table (I did sleep on it one night) that the women labor on when they are 8-9 cm and close to pushing. The room at the main clinic was not much bigger than my bedroom. And it was much, much filthier. The walls have all been painted with a cheap, blue-grey colored paint that is actually more of a brown because of the dirt. I doubt that the walls have ever been scrubbed or washed. Aimee and I spent one evening disinfecting the delivery room as best we could. I swear it was the first time in at least 10 years that the beds had been moved and the walls behind them cleaned. And the bars on the end of the delivery tables, where women hold on as they push, and the edges of the bed that they lean over to spit or vomit, I doubt they had ever been scrubbed either. There were lots of layers to the grime. It was beyond gross. Honestly it was heartbreaking. I was blown away--I am not sure the matrones or the health administration has a concept of germs. For example, there was a limited supply of gloves so the matrones would just keep washing the ones that they had. And although they had working autoclaves (we tested them out) they "sterilized" the instruments in a chemical solution similar to bleach, but the strength of a cleaning product you might use on your kitchen floor and counters. Not strong enough to kill much of anything. And the instruments that were used, that I had to use, weren't very well scrubbed before soaking in the solution. Basically the scissors for cutting umbilical cords, the catheters for urine, the instruments you might, God forbid, use to cut an episiotomy, or repair a tear, they soaked in these plastic green buckets of diluted bleach and floating particles. Yuk. And there weren't many instrument sets, so if three women came in within an hour or two of each other, those instruments were used again, without soaking in the unsanitary bleachy water for very long. The whole picture still blows my mind. The beds, and the instruments, and the curtain. Yes, the curtain. There is a curtain at one of the clinics, that separates the delivery tables from the labor tables and from the outside world. Its purpose I suppose is to provide some sort of privacy. It hangs very close to the main delivery table, so close that when you are standing on one side of the table to support a pushing mom's leg, or to hold her hand or wipe her brow, you brush up against it. Actually it just hangs against you. The curtain is very, very old. And it is very, very dirty. I am sure it, like the walls and beds, rarely, if ever, gets washed. It is decorated with brown blood stains and holes, and dust. I am sure it has had amniotic fluid splashed against it, not to mention vomit. Birth can be very, very messy. Women shit, pee, bleed, gush. If it can come out, it will come out. And if there is a curtain or a table or a towel (I won't even describe those) to splash against, to stain, believe me, it will happen. And there aren't any washers and dryers or big buckets of bleach or cleaning staff, to tidy it all up.
But back to the birthing mothers. It was a big deal to try and get them to change positions. Women pushing on their backs don't have the help of gravity and in school we are taught that it is hard to push a baby's head under the pubic bone if the woman is flat on her back. I have to say that while it looks very uncomfortable, most of the Senegalese women had no trouble birthing their babes. There is more to birthing on the back than just discomfort and a lack of gravity, it can cause problems like decreased fetal heart rate. And at the clinics where I worked, if a mom pushed for more than an hour, the matrones were eager to cut an episiotomy. Not only are episiotomies something that midwives rarely, if ever do, but there is some form to how and when you do them. There was one birth where I literally had to push the matrone and her scissors away from me and the mom's perineum in order to keep her from cutting the episiotomy I had just refused to perform myself. The baby's head wasn't even crowning (meaning that it was still up near the pubic bone and I couldn't even see anything. Generally, if you do have to do the evil procedure, you do it when the head is trying to push past the last bits of tissue, when she is stretched wider than some of us would care to imagine). I thought that the matrone was going to push me back, or push me out of the delivery room, but she just shrugged and looked at me like I was out of my flippin' mind. Luckily we were able to get that particular mom off her back and onto her hands and knees. Getting a birthing mother to change positions, especially while pushing, is no easy thing, even when you can speak the language. We had the help of the matrones, some of whom thought we were nuts, and a beautifully constructed chart depicting a pregnant woman in hands and knees, on her side, in a squat, and being supported by her husband (the last option isn't an option in Senegal. Men are not allowed near the birth room). Hands and knees is a great position for pushing, and was our ideal, since there were no squat bars, and women who changed to their sides inevitably rolled back onto their backs. Some of the matrones were pleased to see that being in hands and knees brought the baby down faster. The sooner the women give birth, the sooner the matrones can return to their other duties (like helping patients who have come in for malaria treatments, premature labor, headaches, and the number one ailment "meti" which is pain). A couple of women upon realizing they could be in whatever position they wanted, grabbed onto that freedom for life. They labored on the floor (which was not as dirty as the clinic walls, it does get mopped most mornings), on various beds, on their sides, in a squat, in a supported squat, anything but their backs. Those births were great triumphs for us. One of my favorites though, was in the last week. A mom who was birthing her eighth or ninth baby was getting frustrated that the baby wasn't coming faster. I asked her if she would like to change positions. We pulled out the chart, pointed at the hands and knees woman, demonstrated the position ourselves. made grunting-pushing noises, told her in wolof/french that the baby would come faster this way. The mom looked at me like I was her worst nightmare. She basically told me that she'd given birth many times before and all of the babies came while she was on her back, and she wasn't going to change that now. And, the problem was that she had to pee and needed a catheter, and oh, where was her IV? Needless to say, she got her catheter and peed, and a long time later birthed the baby. I am sure she went home to her village and told the other women that she had been subjected to the midwifery ways of a white woman and that had caused her to have the longest push in all of her childbirthing history. And who knows, but she is probably right. While some women were very appreciate of our gentleness, I think other's probably thought they were part of something like a science experiment.


Being back is really strange. I can't believe how clean it is! I spent part of a day in Manhattan on my leg home and felt like the streets and sidewalks were clean enough to eat from and the air clear and fresh. And then to arrive in Portland where it is less polluted! It's also strange to see cars parked neatly against sidewalks and I have to remind myself that in America we don't greet every person who glances at us, or walks by. In Senegal there is a long list of greetings that are said to even the random people you pass by and to not answer them is very rude. Its something I wish we did here. It feels good to acknowledge the presence of someone who is just a stranger in the market.
The trip was rewarding in many ways, and it is hard to decide on favorite moments. I caught 19 babies, 7 of which came in the last week on a 48 hour shift and 6 of those came in a space of 16 hours. That was a crazy evening. I never did make it to the twin deliveries (there were two, one of which was on my shift, but I had preceptors reluctant to go to the clinic, so we didn't go in) and I missed the one breech birth. I'm a bit disappointed about that, but the rewards of experiencing 19 other deliveries and one transport are far greater. The transport is probably one of the most rewarding experiences of life to date. I A mom came in with a placental abruption, essentially she was bleeding internally, filling her womb and the amniotic sac around the babe with blood. Its one of the scariest situations in midwifery, and handling it in Africa, with minimal supplies and ambulance rides that are not affordable and take hours is beyond that. t's amazing what 20 American dollars can get you. In this case, a ride to the closest hospital and a life saved. Not to negate the care that Aimee (one of the other students) and I were able to provide, but there is only so much you can do without modern technology and doctors who can perform Cesareans. There really aren't words to describe the experience of sitting next to someone as their spirit decides where to travel next. I have sat with babies as they make the transition from the other world to this, and I have it seems, witnessed them struggle with the choice to stay in this world or return to the spirit realm, and I have been there when the choice was made not to be born into a physical body, but there is something profoundly different in witnessing a mother make those choices as well. There was a moment where I thought she had slipped beyond our medical care, beyond our human understanding, and I thought the mother was going to join her baby and the angels, but she seemed to drift back just as the ambulance was arriving, a couple hours after we knew she would need one. Here, she would have been to the hospital and probably would have been in recovery by then. Time in Africa has its own category--no one is in a hurry, ever, even when its a life and death experience. Once Aimee and I got the mother on the ambulance we had to return to the duties of the clinic. We would have to wait to hear if this woman made it alive to hospital. Hurry up and wait as they say. The mother did indeed make it. And she wouldn't have made it if Aimee and I hadn't had the 10,000 CFA's to pay for the ride. It leaves me with an odd sense of power, disbelief, and gratitude. But the truth is that these choices are not in our hands. We can have the best hospitals and doctors at our fingertips and not make it, and we can be in a tiny African village where time moves at a snails pace; where it takes over two hours for the ambulance that is less than a mile away to get up and running; where ambulances stop to pick up hitchhikers during a transport, and there are no EMT's riding in the back, and we can make it. We truly are led by the divine and in the hands of the divine and we really have not other option than to surrender.
The family was so appreciative---the families in general were very appreciative. I had a baby named after me, and a couple of moms that were happy to give me one of their children. Including the mother of the twins who's birth I missed. She would be happy to share one of her babies with the American. The people were easy to communicate with, despite the language barrier. Hand gestures and humor get you far. Bargaining in the market was lots of fun, as was having clothing made. Aimee and I had quite a time trying to communicate about dress style and size with the dressmaker who spoke only Wolof---we couldn't get by on Aimee's french this time around. Needless to say, we have Senegalese outfits that do actually fit and I received my second marriage proposal (this was early on in the trip, there were more proposals and refusals made). It's an honor to be the second wife, its actually the preferred marital spot, so I guess I should feel blessed that no one wanted me as a first wife (those wives are really only good for cleaning and cooking). Another highlight was having prayer ties made and relay race of communication that happened around that. It was a big deal that I was even asking to have prayer bags made, me being a non-muslim and an American. This man, probably in his 50's sat under a big neem tree just about every day making these medicine bags. The women and the men wear them around their arms or waists--they are considered powerfully protective and can bring many blessing. The women don't remove them during birth and the babies are given theirs in the first hours postpartum. The prayers are written on long strips of brown paper and then tightly folded and wrapped in colorful leather. The leather is sewn around the paper so that each pouch is sealed. A few of the pouches contain a piece of bone, often a horn. Of course I wanted a horn too, but that was lost in the translation. I am not sure if that was asking too much or if the man just didn't get the message. In any case it took a lot of work to have this piece made. It took my dramatic hand gestures and limited Wolof phrases (including one that translates to "slowly slowly the monkey comes out of the jungle" meaning "I'm sorry I am a foreigner who didn't bother to take the time to learn your language, but I am trying") Aimee's french, a man who translated some of english and some of our french into wolof, another man who translated some of Aimee's french into wolof, a handful of observes, a few children, our taxi driver, his friend (who offered me the last marriage proposal of the trip, once again as second wife) and of course the artist making the bag to get the job done. It was a priceless experience. And I am sure the man making bag was happy to get good payment for his efforts, and I am sure he was relieved that I had refused his marriage proposal (given a week earlier) as I think he realized American women are more trouble than they are worth and wouldn't be very useful wives. By the way, there is a group of men wandering the streets of Mboro waiting for some American women to arrive. Aimee and I promised them that we would send our single female friends their way.

Anyway, that's all I can process for now. It's a lot to filter through!