The Privilege of Self-Reflection

6.26-We’re in the middle of our third week. I can’t believe it. My days are booked. Today Rachel and I are working the evening shift at the hospital so I have the morning to write and catch up on some things around St. Monica’s. After lunch, we’re teaching a workshop with the child mothers that live and go to school here. Sister Rosemary asked us to teach them a course about mothering, focusing on the basics of washing and caring for their baby etc. We’re hoping to have more of a conversation around the joys and challenges about being a young mother. We’ll see how it goes…

Well, I’m finally feeling like I’m gaining clarity on the purpose of this trip. Our meetings with the TBAs have pointed most directly to what’s most needed and what can be most easily sustained. My heart is with them. They are a vital part of the health care system in the North. They are not compensated for their work in any way. Yet, they identified so strongly with being a TBA as a profession. It is their profession. They are proud and passionate about their work. If they’re lucky they’ll receive some sugar or sim sim (peanut) paste as payment for a birth. Most of the time they are not paid. They have been forced to move into IDP camps because of the conflict, without any support from the government at all or any supplies to protect themselves. They attend births often unprotected without any gloves. They shared with us about their concern about contracting HIV and other diseases. Some have been living in the camps for a few years, some up to twenty years. Once again, women are carrying the heaviest load for their community without any recognition, training, funding, or outside support. This is what feels important to me. Each group that we’ve met with has a leader. It would be feasible to implement a program to support the TBAs through local leadership to get them supplies, funding, and training. I believe that with long-term governmental and NGO support these women could change the structure of healthcare for women living in IDP camps. They have sincerely asked us not to forget them.

The hospital is another story. The need for supplies and training is also very great. I filmed and witnessed a cesarean birth two days ago and was horrified at what I saw. It is not their fault. To begin with, the two surgeons performing the procedure were both junior doctors. They have been trained in an outdated technique. I watched in horror as this poor woman was butchered with a 10 inch midline incision. Blood was pouring off the table as she lay with her scarred uterus on her stomach and her placenta in between her ankles (they just left it there). To everyone’s surprise she gave birth to twin girls. I honestly wasn’t sure if she would make it out alive. Thank g-d she was in the cesarean ward the following day. She is in severe pain but she is alive. This was her second cesarean. Each day at the hospital is horrifying. I wish it wasn’t this way.

One thing that I have found here is the absence of critical thinking. As a culture, they have been taught not to question. The roots of this absence come from the conditioning of being colonized. There is a formula for everything they do. Thinking outside of the box is not even an option. There is no awareness that there is a box. There is a lack of self-reflection. I see how in our culture, self-reflection is a privilege. This is extremely disturbing when it comes to birth, an art that so heavily relies on intuition. From the time we are very young, our parents ask “How do you feel, honey? Did that make you feel sad? Did your feelings get hurt?” Your feelings are a privilege. I am constantly trying to find ways to reframe that question. It just doesn’t translate here. Kevin is finding the same thing with his work at the prison. The men there are most comfortable being a collective, but to ask someone to individualize a performance is foreign to them. It took him 45 minutes the other day to have them act out something from their own experience. The removal of one’s own personal experience from the culture plays into birth in a fascinating way. You might think that women would birth silently, shamefully, or introspectively due to a lack of individualism and self-reflection in the culture. But we’re finding the opposite. Birth gives these women permission to emote and be dramatic. It gives them permission to feel, shout, scream, rage, and cry. It’s an eruption of emotion! The midwives in response will laugh and call them “stubborn”. The performance of birth comes to a screeching halt after the baby is born. A woman that was tearing at my neck and kicking me one moment becomes immediately docile and expressionless after the birth. Or she goes from a raging fit to being so lovely and sweet.

Last week, a young midwife, Beatrice, fresh out of midwifery school joined us on the maternity ward at GRRH. She is obsessed with conducting every birth and in my opinion, a little “catch obsessed”. Each birth is approached the same way as if each mother’s needs are the same. I appreciate her passion for wanting to learn. I share that passion with her. But what I’m witnessing her practice is actually dangerous to the mother. She was taught to do thorough vaginal examines after a mother has delivered. As a student in this system (British) you are taught to learn through rote memorization. That is they way to succeed. Do as the book says. So even if we have controlled a mother’s bleeding with nursing or breast stimulation, she insists on vigorously inserting her hands inside a woman after each birth. One of the last mother’s that this happened to fainted in the hallway five minutes after being examined in this way. It’s disconcerting to say the least. We are always walking such a fine line. A dangerous line. An important line. There is a time and place to step in and protect mothers, to actively train the other birth attendants and midwives, and there is a time to respect their practices and watch. I do not blame the women that I’m working with for what I see as negligence. It would be naïve and arrogant to do so. The problem runs so deep, and is a direct consequence of the effects of colonization. But at what point, as a culture, do you evolve from that history? Where does critical thinking come from? As a culture, what is the catalyst for questioning? Rachel calls it “a shell of Western medicine”. It’s true. It reminds me of how women were treated in the nineteen fifties when the medicalization of women became the trend, and sadly, remains as the dominant paradigm. So here we are…and this is the “referral” hospital that the TBAs are being told to send their women. This the place for high-risk mothers. This week one of the mothers came in with a prolapsed uterus. Her uterus was still hanging out of her vagina two days after she first came in. She left and went home untreated.

We’re filming our days here with the hope of creating a documentary that will not only tell the story of the hospital, but help to raise funding and awareness for the TBAs. Soon, two more doulas will be joining us. That said, I question if an exchange program is what is most needed here. If my intention is to create a sustainable project for TBAs I have to be honest and say that it is not about bringing more of “us” here.

July 27th – I’m returning from a very upsetting day at the hospital. It is honestly just getting worse and worse. We came for the evening shift and found out that one of the mothers lost her baby in a cesarean section. It took a few minutes to find out that it was Harriet’s, a seventeen year old girl that I was with all yesterday. When I left her at 4pm she was 8cm dilated, the heart rate of her baby was strong, and she was in good spirits. We spent most of the day walking the halls and singing a song that we made up. “Today is the day of birthday. Today is the day for your baby to come...” then I would ask her, “When will your baby come?” “Today!” When will it happen?” “Now!” and she would point to her belly. Then she would tell me that she thought we should switch bellies. She wanted me to have the big one! I asked her when this should happen and she responded “Tonight!”. We laughed together and kept on walking. Out of all the teenagers that I’ve worked with I felt most connected to her. She was responsive in a way that I hadn’t experienced with other girls. She had a large group of mothers helping her, supporting, and loving her. It was shock to come back today to the news that her baby had died. What happened?! What went wrong?! I was not satisfied with the doctor’s explanation that her pelvis was compressed. He said that he got a call at 1:30am but he was not on-call that night. He tried three other doctors and not one of them answered the call. Apparently, one was officially on-call but his phone was off. So he waited until the his morning shift and gave her the cesarean at 9am. By that time the baby had already died. I went to see her in the cesarean ward. A ward filled with about ten beds full of recovering mothers, most with infected incisions. The room smells like shit and piss and is full of flies. I don’t think the mothers get cleaned up or cared for. Usually one of their relatives is responsible for washing them. She looked at me asked about her baby. I couldn’t believe it. I didn’t understand. No one had told her that baby died. It was explained to me later that the policy is to wait a few days until the mother has recovered. I spoke with the doctor again (the junior surgeon who performed the cesarean). I told him that she was awake and that she had been asking for her baby. We walked to the ward and I thought he was going to give her news. Instead, he lied to her and told her that the baby was not well but that we’re hoping he will be better by tomorrow. He was speaking in Luo so I thought the whole time that he was telling her truth. Instead, he lied to her face and to mine. There was nothing I could do except hold her hand and be with her. I left it up to her mother to tell her, but I don’t think she has. Her family had been informed and had taken the baby home after the cesarean. It wasn’t until a few hours later when Harriet was asleep that I got the real story. I took her mother outside in the hall along with a translator to find out what went wrong. The translator was this wonderful woman who has been working at GRRH in the dental ward for ten years. I was told that she was 9 cm at 9:30pm. She felt the urge to push but was told that she was going to get slapped if she cried or screamed. The midwives then went into the back room (the room were we change) and slept throughout the night. They told the mother and Harriet that they would only come out to clamp and cut the cord. They totally left her alone. They abandoned her. Her mother said that no one touched her, no one encouraged her, or helped her. About an hour later she was pushing on her own. The baby came down and was close to crowning because her mother said she could see head. Again, no one came to be her, check the fetal heart rate, or help her push her baby out. They left her in that state until morning. The baby was in distress with his head compressed in the birth canal for twelve hours. Of course, by the time they performed the cesarean in the morning he was dead. The mother said to me that she thought of us all night because she knew we would have helped her daughter. She said she knew we would have touched her. The woman translating, Janet, was extremely open and told me that this happened too often at this hospital. “The midwives hit and hurt the women. They should not treat mothers this way. They should be encouraging them, especially such a young girl.”
My blood rushed through my body. I was livid. An entire month of justifying, of playing mediator and peacemaker, came to an end. What is happening at this hospital is criminal. I’m sorry to say it. It needs to be reported to the administration. It needs to change. I apologized to Harriet’s mother. I told her this should not have happened to her daughter. I asked her if I could film her story with Janet translating and she agreed. I’m going to return to the hospital today to follow-up with that and a few other things. My heart is so heavy. There’s really no time to process here. I just seem to be moving on. There are so many issues colliding at once. I’m reflecting on my first time at GRRH. What was the difference? The majority of my time, I was working with two other midwives, Jackie and Jennifer. I haven’t worked a shift with either one of them this trip. Compared to the midwives of this trip, they both are kind, knowledgeable, and thorough in the care of mother and baby. They taught me a lot. In that time, I never witnessed a resuscitation. I never saw a baby die. I knew the conditions were atrocious but I felt that the mothers were being cared for.

This type of violence against women happens all over the world. It is another case of victim/victimizer. The truth is I have compassion for the midwives abusing these women. I see how little they have, how unsupported they are. But this can’t go on… Will my reporting them really do anything? I doubt it. But I feel like I can’t leave here without handing in a formal report on the conditions that we’ve witnessed. I do feel clearer about my own role at the hospital. I’m putting my energy into educating. I don’t want to reprimand or continue the violence I’ve witnessed by assaulting my midwife sisters. I want there to be real rehabilitation for the women and staff. I even thought about incorporating non-violent communication into the next trip (who knows when that will even be?).

Sorry for the extremely long blog. I’m really just journaling for my own sanity. It helps to write. The week in Rwanda is looking really good right now!

Love to you all. Thank you for your support and Love. I feel it. The work is hard but I love it, and it's what I came here to do.

Ps Update on Kevin:
Kevin told me that he plans to post a blog this week. He just hasn’t felt like writing. He’s working at the prison everyday from 9-12. He’s also advising the NYU students on the Teachers for Teachers program. It’s all going well. Unfortunately, he got sick last week but has made a full recovery! We have our “dates” throughout the day and week. But we’re really looking forward to an enjoyable last week together in Rwanda. And we can’t wait for gorilla tracking on our last day!

Love,
Aimee


Photo Kevin's first night out after a week of being sick!
Photo Sister Florence, our Ugandan mother who we love so much.
Photo Harriet in labor