A fine balance

I haven't known how to write this blog post.
How to share what is joy for many mothers, but an incredible loss for a few.
Why is it that the pain can feel so much heavier than the joy? Even when joy is all around you?

I hope I can describe the joy but acknowledge the pain.

There are 6 beds in the labour and delivery ward. They are not the fancy beds you might picture when thinking about your own birth experience. They are very simple, very well used metal beds with a thin, vinyl covered mattresses. They are always full. The rotation of women giving birth does not stop. It may give a reprieve for 20 or so odd minutes, but babies do not yet tell time or know the importance of a tea break, and so the bed is soon occupied. At times, even a mattress has to be pulled from the antenatal section and placed somewhere in the middle of the room for a 7th mother to be monitored. Or for a woman in severe eclampsia to be under the watchful eye of the nurses.

One young mother did not even make it to the bench. After taking herbal medicines in the village that induce labour, she gave birth on the floor under the sink before a nurse could even usher her further into the room.

I am often overwhelmed by the number of urgent situations that never cease. I told the nurses that in Canada, each one of these situations would require what is called a "Code team" and there would be masses of people surrounding each "emergency". But the nurses are so calm and cool and take it all in stride. This is what they do. Every day. All day.

Once the baby is wrapped and the mother is stable, she quickly moves to the post-natal ward. Along with the antenatal (before giving birth), it is the most congested part of the hospital. Two women share a bed, along with their babies, carefully curled like 2 question marks at each end of the bed. They take a bit of time to recover but as soon as it is evident that the baby is breastfeeding and the mother has no complications, she is discharged home after about 6 hours.

The women who have undergone C-sections after prolonged or obstructed labour are in a separate section and the positive unintended consequence of having major surgery is that they get their own bed! They stay for 3 days, barring no infections or further complications with instructions to return in a week to have their sutures removed.

And then the "Kangaroo room". Aside from 2 incubators that are never turned on (I'm not sure they even work), premature babies are cared for in this heated room, utilizing the best "technology" out there - skin-to-skin contact with their mothers. They receive extra education about nutrition and caring for their tiny infant. Some of the babies are born weighing less than 1kg. I weighed all the preemies one day. The mothers eagerly anticipating some weight gain, eyeing the mechanical scale carefully, and squealing for joy when the scale was tipped higher than last week.

Each day brings so much joy to so many families. The healthy triplets born to a mother of 9 children.  The baby that cried heartily after a painful birth. The mother that makes it to the operating room to stop the excessive bleeding to save her life. I should be walking on a cloud with all the new life around me!

But there, too, is pain. On a particularly difficult day, I walked into the labour and delivery ward to see a full-term infant lying lifeless at the end of the delivery table. Suffocated by the cord that had given him life for 9 months. Then the surgical delivery of a 7 month old lifeless fetus that had suffered placenta previa. The placenta had become detached from the mothers uterus, and the flow of blood to nourish the baby had stopped. And another baby born stillborn. And yet another mother referred in from another health centre with no fetal activity. Everyone around me looking so stoic and continuing on with the day. I wanted to stop the world from revolving and shout "this isn't supposed to happen!! Why aren't people crying?" I wanted to shout against the injustice of this! But I too, had to continue on with my day. My whispered "pole sana Mama" (I'm very sorry Mama) quietly acknowledged by the mother who likely knows this grief all too well.

It is a fine balance to give time and voice to the pain and loss but not to detract from the joy of new life that otherwise surrounds me.

It would be very easy to allow anger at the injustice and inequities of maternal health in Tanzania take over and outweigh the joy. In fact, that would be the easy way out. But I don't like taking the easy way out. I try to tip the balance towards joy, towards strength, towards resilience, towards progress.

And so my approach, against all the odds, is one of a strengths-based perspective.

When I asked "What are your strengths here in the maternity ward?" the answer was,

"We come to work every day because of what we call "huduma ya moyo" or "caring from the heart".

The scale is tipping already.

Tabora homestead

It's always nice to have a visual understanding of where someone lives when they go on to tell a story. So, if you see on Facebook that I've posted that the power is out or that I want the lizards to eat more insects, feast your eyes on my humble abode.

Although sometimes I feel like a pioneer (baking my own gluten free bread, warming up bath water in a pail in order to bathe), I actually have it pretty good. I have running water, a toilet, a bedroom with a closet, a shelf, a kitchen equipped with a stove, fridge, and freezer, a front yard, and about 100 pet lizards that feed themselves. What more can one ask for!

Here is a link to the facebook album
https://www.facebook.com/media/set/?set=a.10152822770850295.1073741849.528770294&type=1&l=af76fca830

I've added photos below, but not sure why it won't let me rearrange them... however, they are self explanatory.

you're welcome to stop by any time!
Karibu sana!

iCare

Care? Care what? Who Cares? You Care? What's Care? i Care?

These are some of the responses I've fielded when explaining that I was going overseas with CARE.

When they thought I was saying an acronym, then I would said, "Care, you know like 'I care'" and one would say "You care what?" I almost started calling the organization "iCare". I've started just saying "CARE Canada" or "CARE International" because somehow the second word makes it sound more official.

So, what is CARE anyway?

Well, as per their website, CARE started as an effort to deliver "care" packages to people in Europe after World War II. Over the past several decades, their work as evolved into focusing on emergency relief, economic development, food security, and maternal health. What attracted me to look more closely at the organization was that in their mission and vision statement, they reference wanting to work with the poorest communities that are not well served by other organizations.

          We seek a world of hope, tolerance and social justice, 

where poverty has been overcome and people live in  dignity and security.

So, I applied and was accepted as a "Volunteer Nurse Advisor" under the umbrella of a maternal health program already well underway in the Tabora region of Tanzania. 

In 2010, the G8 leaders committed to financially supporting initiatives to improve maternal, newborn, and child health and  called it the Muskoka initiative.  (Every time I hear a Tanzanian say it, I think of some woods in Ontario, and momentarily wonder why we are discussing the Canadian wilderness....)

With funding from the Canadian government, CARE proposed and has implemented the TABASAM project - or the Tabora Adolescent and Safe Motherhood - project. (Don't worry, there won't be quiz on acronyms!)

To start, Tabora is not an easy place to get to. It is a 17 hour drive from the coastal capital of Tanzania (Dar es Salaam) and the only airplane that used to fly here is now totally broken (the engine failed and had to do an emergency landing). It is a mere 6 hour drive from Mwanza, on Lake Victoria on dusty, bumpy roads. Thus, it is also not a very popular place to do development work. Unlike many other easily accessible African towns and cities, you don't see NGO signs and landrovers of NGOs dotting the landscape every where you go. According to the last unofficial head count, there were only 42 foreigners in this town of at least 150,000, and most of those people are in the tobacco industry. 

There is not much around other than farms; no beaches to lay on, no mountains to climb, and no lions to watch. The wikipedia page and Lonely planet say this about the town of Tabora:

Tabora does not have many tourist attractions. 

It is well off the beaten track, with few tourists.

In my ancedotal experience, it is the places the hardest to get to and are least "interesting" that are the least served and have some of the worst statistics for health, education, and development. So, I am actually pretty pleased with the fact that CARE chose this area for their work - because it is so under-served. 

Working in close cooperation with the Tanzania government at all levels, CARE has implemented advanced training for Community Health Workers (CHW) focusing on maternal and reproductive health. Nearly 1,000 workers have been trained and equipped with a bicycle, t-shirt and small monthly stipend to work in their communities to educate and monitor pregnant women, promote family planning, and facilitate referrals to appropriate health centres if concerns or complications present. The CHWs with this advanced training are present in 176 clinics/dispensaries and 56% of government facilities across all of the districts in the Tabora region (kind of like a province).

An area that the project has not focused on is the hospitals as it has been assumed that they were equipped with the necessary infrastructure and support to handle the complex maternal cases.  The hospital administrator is very appreciative of the work of CARE in the community and so asked if they could receive some support in the hospital. And this is how my position came about.

While my career experience has not been in maternal health, my interests lie in helping people assess and improve their workplace and health practices. And while the Tanzania health staff told me I'd be delivering babies "by next week", I have only gone as far as rubbing a labouring woman's back or weighing some preemies :-) and I think I should keep it that way! The staff are fully capable and are experts at their jobs - I am certainly not there to teach them how to deliver babies! Rather, I will work alongside them to try to improve the workplace in which they deliver the babies. 

In upcoming blog posts, I will describe "a day in the life of the maternity ward" - and it will guarantee to shock and surprise - in both postive and heart breaking ways. 

(p.s. you are under no obligation, but if you are interested in giving a "CAREing" gift for friends and family at Christmas, giving one of these presents instead of another sweater or tie is a great idea!)