Out Walking

A couple of weeks ago the now dead head-high grass surrounding all the hospital buildings had finally dried out enough to be cut down and stacked, and later carted  off to be used, I think, as thatching . I had been waiting for this to be done ever since I arrived because the  tall grass blocks the view from my front door of the row of village houses and all the animal and human traffic that passes by on the other side of the hospital fence 10 meters away. A common sight now revealed again, one that put me off my morning coffee was children squatting down not far from the fence to poo on the open ground . But my eye was always drawn to a distant upward  sloping horizon across which on market days could be seen a steady stream of tiny figures creeping slowly toward town, and in the evening back again along a country trail. I often wondered where they had come from and what was over the horizon - until yesterday when I at last got to walk there.

Villagers on the road

This track turned out to be the path to a waterfall that I had been hearing about, that other volunteers here had visited , and which I decided yesterday afternoon I also should visit, and I set off at about 5 pm with Shewaye and Anna , a volunteer midwife who arrived last weekend. She has been here before and had already visited the waterfall but was keen to go again. In the end, because of fading light we stopped short of the waterfall but had a good view of it from a distance as the sun was going down behind us. The walk across the fields had taken us out of the town, past one of those lovely circular churches, and near a small cluster of homes.

Heading home

On our return we were invited to drink “‘tulla” which is home brewed beer, and given some flat home cooked bread to eat by a group of people working on a huge heap of recently harvested teff. They were extracting the tiny seeds by spreading the teff stalks across a circular sort of arena, then having their cattle walk round and round on it and lifting off the depleted stalks with an angled stick, leaving the tiny seeds and lots of chaff on the ground. Later the seeds and the chaff would be further separated by throwing it high into the air in a light breeze. They had no doubt been working there all day long and seemed glad of an opportunity to crowd around and have their photos taken – they were lovely friendly people, and obviously very poor .

Looking at their Pictures

 

As it got dark and we headed back to Motta, half an hours walk away, we started to hear the noise of the town and see the dust rising from the road as a bus rumbled past, a few lights – Motta suddenly seemed like a big place! And then my phone rang and we quickened our pace to get back and see someone the midwives were worried about. Its tempting to get misty eyed and sentimental about the sort of simple village life we had just glimpsed – and I think if you weren’t old or sick, or in labour in such a place,  there would be times when it could probably provide  just about everything you could want. Certainly the kids seemed happy.

Ragged clothes worn till they fall off

Back in Motta, we quickly sorted out the problem and then had dinner. Since Anna got here last week we have been sharing the cooking, and it was her turn and we had a pasta dish with local spinach and the first cheese Ive had this year because Anna had bought with her a big ball of lovely dutch cheese. The previous night she had made a tasty salad to supplement fish cakes that I had made. 

Today is Saturday but I wont be going to the market. Instead, I am packing up my stuff and leaving for Bahar Dar, as my two month spell comes to an end. In an hour or two my replacement should be arriving – I hope they are sending her in a more reliable vehicle than they one that was supposed to bring me here – otherwise she might end up on the bus and not get here till 8pm. However  I am not leaving Ethiopia for another two weeks, as I am going to have a holiday with Ewin who flies here in a few days – we are going to tour the southern parts of Ethiopia. Not sure how much internet access I will find down there but the next few days I will be in Addis.

Shit Happens

Builder at Motta Hospital

There are proper toilets in all the buildings at the Motta Hospital, and a shower is included in several of them but because for  many years there has been no running water all of the toilets and showers are “non functional”. In the unit that I stay in, the toilet is still connected to some sort of septic system, so I can flush it by tipping half a bucket of water in, but the shower isn’t usable. To have a shower I heat water up on the stove and use it to warm up another half bucket and tip the water over me from a small plastic jug.

In recent months  parts of the hospital  have reacquired running water to a few taps and a couple of showers : these are the Maternity Unit, and the Operating Theatre, which apart from being the place where young men get circumcisions, is almost exclusively used by the Obstetricians for caesareans. These select areas have running water only because a few months ago a guy called Brad, the husband of one of the Farenji  volunteer midwives from Australia, decided to make himself useful while here and get it all working again. I take my hat off to him: to get something done like that, which included digging out the half filled old hospital well and getting a new pump installed and connected is no mean achievement in the culture that exists here. His contribution has made a huge difference to hygiene and the  general state of cleanliness in the Maternity ward, which for years previously  used water from  a single large plastic water container that required refilling from a tap 100 yards away every morning.

The new Hole

The toilets themselves have been non-functional for all these years as well, and instead patients use a smelly rickety tin shed in the nearby field with squat toilets over a deep hole. There is no lighting to it and the path is just a worn track through the grass. The deep hole must be getting near capacity because over the last few weeks a new one has been dug and a new toilet facility is being erected over it. The new hole, 20 feet deep was dug by several men with picks shovels, a bucket on a rope and a ladder, and it took about a week. It is lined with narrow eucalypt tree branches, which have all been chopped down locally and trimmed to size with axes and adzes whose handles are appropriately shaped limbs of a tough tree. Walls, the roof and doors are all corrugated iron nailed to a frame of more tree branches set into the earth, but as yet the flooring consists entirely of more tree branches’ laid across in two layers at right angles – somehow I think concrete  will be laid on top of them to make a floor.  Its been quite an education to see this structure being literally hand made and using branches and tree trunks rather than dressed timber

New Toilet nearing completion

One wonders what sort of budget the hospital must be managing on if this is the sort of construction method employed for something as important as toilets, and there was never enough money to re-establish the water supply.  But then, I discovered the other day that there is no Electro-cardiograph machine in the hospital – this is a fundamental piece of equipment used in the investigation of all manner of cardiac diseases and would be regarded as  essential in any western hospital. An ECG machine is not an expensive item, but apparently it also is too expensive for Motta. I also learned they would not be able to afford locally trained Ethiopian Obstetricians like myself – when one was employed to cover an unexpected gap in the supply of volunteers last year, he agreed to come only if the Barbara May Foundation paid him the equivalent of more than ten times the salary of the local General Practitioners, who by Ethiopian standards are already well paid!

Brads was not the only water project in the area : when I was here a year ago I would often run into a charming guy down at the Wubet Hotel who was a manager of a huge water project for the town. It was funded from overseas to the tune of something like a million Euros. His team had been drilling for water and planning a reservoir somewhere nearby, had a couple of nice white Toyota Landcruisers, mobile phones and requirements for lots of meetings and travel in conjunction with the Project. Enquiring about how the Project was going this year, after having realised this guy was no longer around, I was told most of the wells were dry, the guy in charge had been moved on and had apparently been rorting the finances by such devices as claiming wages for fictitious employees, and the project was probably going to be abandoned as the funds were nearly all exhausted! Even the hospital water scheme wasn’t spared this sort of scam : poor Brad was asked to send a large sum of money to pay import tax on a new pump he sent from Australia after he got back, but the person asking for it had nothing to do with the hospital and simply pocketed the money and left the pump at the airport in Addis. In contrast, somehow I don’t think the poor hardworking guys building the new toilets are finding much to rort. The irony is that in poverty stricken countries where  the temptation to help yourself to seemingly limitless Farenji  money is too great for some, the crooks are usually in the ranks of the  comparatively well off – the really poor don’t have the education or the means to participate in rorts and scams, other than perhaps asking a bit more for their onions and cabbages at the markets.

The Spice of Life

Tea and Coffee Pots

Ive often wondered why it is that for most of us in the west we have almost the same thing for breakfast every morning, but insist on almost never having the same thing for dinner two nights in a row. Ethiopians don’t seem to have this problem – they eat injera at almost every meal, and the range of spices and sauces and vegetables they eat with it is quite limited, but they are, to a man – and woman – incredibly enthusiastic about the stuff. Whereas  we in the west are mostly quite curious about the foods of other nations, and we like to try it – Japanese, Chinese, Thai, Malaysian, Spanish, Italian, Mexican, Indian - anything really - Ethiopians – well the ones around here - seem not to be, and  for them, gastronomically, variety is NOT the spice of life : Injera is. They seem never happier than when upending a dish of spicy sauce onto a plate of fresh injera and using the right hand tearing the injera into pieces and scooping up the sauce and vegetables a mouthful at a time. 

"Scrambled Injera" is Injera with Injera on top

I have grown accustomed to Injera and some of the ways its served;  I had some today with cooked diced meat and onion and spices at the Wubet  Hotel for lunch, and enjoyed it, could probably live on it of I had to, but I know what I prefer to eat, though mostly what I prefer  is not available here. What IS available is a limited range of vegetables –tomatoes, onions, cabbage, green peppers, potatoes carrots and beetroot – banana, limes and bread, as well as many spices, ginger, eggs and pasta in a couple of shapes, spaghetti and rice. There are also the scrawny chickens, and in the little stores I can buy small tins of shredded tuna fish swimming in oil, and fancy biscuits which are very small and manufactured with some sort of drying agent which turns each tiny biscuit into about the most drying and water absorbent object known to man – it makes the inside of your mouth feel as if its been wiped dry with a handful of dust, so must be ingested with coffee or tea on standby. So these are the supplies I have been keeping stocked up on, and from which I make my meals.

Dabo and Mus = bread and bananas

Typically I have coffee and a bread roll with a small banana inside for breakfast. Sometimes its just coffee.  At morning tea time I have a tiny cup of sweet tea and a sambusa  from the hospital kiosk, and for lunch more bread roll with tomatoes and green pepper , or another banana or  slices of beetroot – a cup of tea and a packet of those tiny biscuits – there are 6 and they cost 12 cents a packet! I also buy lollies at 1 birr each – the same as a nice banana but I have to indulge my sweet tooth somehow.

Everything chopped up in a pan, with Rice or Pasta

For my dinner I typically chop up tomatoes, onions cabbage and ginger, fry them in a little oil, then add a tin of tuna fish, perhaps some tomato paste and water, juice of a lime and then  eat it with rice or pasta. I usually have some left over for breakfast or lunch the next day when I might supplement it with scrambled egg which is made with NZ powdered milk. I can also make a kind of soup with all the same vegetables chopped up and boiled for ages with two cups of split yellow peas or lentils, and I eat that with bread. The chicken pieces I thaw to use instead of the fish, but have only had four such meals as I gave some of my chicken to Shewayes famly for Xmas. And sometimes I just have all the chopped up vegetables and rice with a bit of local spice added. A couple of times I have made fried fish cakes from mashed up potato and the same tinned tuna, but essentially I seem to be living on bread, tomatoes and onions, tuna, cabbage  beetroot and eggs. I was really hungry a lot of the time in the first two or three weeks, but I think my stomach has shrunk to match the reduced volume of food I am eating, and I know I eat a lot less than I used to but nowadays I hardly ever feel hungry. I think my more or less vegetarian diet may be good for me – but the food I think about most when imagining being home again, is a juicy medium rare salty lamb chop cooked on a BBQ. 

Tuesday : Part Two

Clothes drying in the sun

 Uterine rupture is one of the most feared labour complications because it frequently results in the mothers death. The midwifes call brought an abrupt end to my relaxing afternoon, and I hurried over to maternity, where I found a desperately ill young woman with the classic sign of uterine rupture : the so-called “Bandl’s Ring”.  What you see in a woman lying on her bed is that her abdomen, instead of rising up to a smooth hump then down again, has two humps instead of one, the trough between them being the “Ring” where the uterus has split apart almost into two pieces. I wanted to take a photo of it but there was no time – she had unrecordable Blood Pressure, was barely able to open her eyes and her pulse was 150 beats per minute. The baby of course was long dead.

 We started fluid resuscitation, gave her what antibiotics we had available and I inserted a catheter into her bladder – pure blood came out and nothing else. We sent relatives to see if any had compatible blood but none did and then we had to try to decide what to do. It was suggested we should send her to Bahar Dar – blood would be more readily available there – but I was in no doubt – she would be dead before she got there.  “no” I said “She is too sick to send away”  And later I found out that the hospital vehicles are still non-funtional, so we wouldn’t hahve been able to send her way even if had wanted to.

 My anaesthetist hesitated once we got her down to the Operating theatre – her pulse was 170 – he mentioned that in Ethiopia it is regarded as a particularly bad thing for someone to have died in the Operating room – better that they die with the family. Should we just send her back? Her blood pressure was still too low to measure and nothing else had appeared in her urine bag apart from blood. It was tempting – the surgery was going to be complicated and even if technically successful it seemed she may not recover – there was no blood, we coudnt get all the antibiotics we needed, her kidneys seemed to have shut down – was this perhaps one of those moments when instead of blundering on and doing heroic surgery that wouldn’t affect the outcome, it would be better to face reality and allow her to die with some sort of dignity, rather than just mutilate her and return a corpse to the family tearfully waiting in the dark outside the operating theatre? Once before I had faced a dilemma like this – it was a year ago in this same theatre when we began surgery for a ruptured uterus and found such damage to the uterus and the bladder I was urged to give up, to not even try to repair the mess. But then I reasoned there was nothing to lose by trying, so I did, and ultimately my Heath-Robinson bladder repair and ureteric reanastomosis saved her life – I was as surprised as anyone, having never before even observed let alone actually performed such surgery. It is a horribly difficult dilemma to face but I decided again that I would not give up without making some sort of attempt to save her. “OK” my anaesthetist said, “Can start” and he put her to sleep

New, still empty homes on the outskirts of Motta

Half an hour later, the operation was over. But it wasn’t the operation I had been expecting to do because on opening the abdomen to our shock – and relief – the uterus was not ruptured though it was close to doing so. The lower of the two “humps” visible externally turned out to be a swollen oedematous and badly traumatised lower segment of the uterus and  bladder, and so all I needed to do was a straightforward caesarean. I extracted the dead and putrid baby, removed the placenta and closed everything up again. Bleeding had been minimal. She woke slowly – we all felt a surge of hope and excitement – she would probably survive.  Thank goodness we hadn’t just sent her back to die!    

 

Tuesday Part One

That Church

Yesterday was interesting for its contrasts. It was a beautiful warm day with hardly any wind, and at about 4pm, very little having happened all day, I decided to go for a walk back to that lovely church among the trees. I had prints of the photo of the guard and the half blind nun to give them, and also sad news that there were no immediate plans for an Eye surgeon to visit Motta.

 I remember his visit last year when I was here : literally hundreds of people turned up one morning, near blind elderly men and women and family members looking after them. They sat on the ground all round the hospital, were eventually all assessed and the lucky few, probably 20 or 30 with the worst cataracts were operated on over the following day or two, and again they sat around outside after their surgery with a patch over one eye. I couldn’t find out why this obviously much needed service isn’t operating any more, but continuity and reliability in terms of service delivery in this part of the world can never be counted on – whether its to do with funding or some other vagary I have no idea. A case in point from yesterday – we needed some critical IV antibiotics for the woman I will describe later – but the Pharmacy had none left! Today, investigating this ridiculous situation I discovered there are actually THREE Pharmacies in this hospital – one for Inpatients, one for Outpatients and one for Clinic patients – and they don’t appear to communicate with each other because I discovered the antibiotic we needed was still available at one of the other “Pharmacies”. I suppose it keeps people in jobs if you have three of the same thing in one tiny hospital but how wastefully inefficient, and how hopeless that the Inpatient one not only allowed its stock to run right out but had no idea that the drug was available at the other “Pharmacy” about 20 meters away! Meanwhile my patient is receiving inadequate treatment, maybe even dying because of office inefficiency.

 So, as usual I set off by a different route to the Church. Ive noticed the further away I get from the hospital the less irritating the children are – the ones near the hospital have recently started throwing stones and dust at me and sneaking up behind me to poke me with a stick. This no doubt is the result of a couple of changes in my own behaviour – for one, nowadays I mostly ignore the chorus of “Hi” “Faranji” “Give money” etc etc that are yelled at me by every kid under about 12 that sees me, even if I am 100 yards away they scream out at me and expect me to turn and wave or call back – which I used to do but eventually one wishes for some peace and quiet when walking the streets, to be left alone with ones own thoughts and not have every ragged kid regard me as some sort of mobile entertainment centre. The other thing that happened was when walking alone one evening recently I spied twin baby goats and their mother nestled down among some small trees in the late afternoon sun : a beautiful picture waiting to be snapped, so I quietly approached and was quite close, getting my camera out when suddenly the cry went up “Faranji, Faranji” ( it means Foreigner) Within seconds a horde of screaming children started racing across from around a nearby corner, “Faranji, Faranji, Hi Hi, give money…” and of course the startled goat stood up and so did her twins, the moment was lost, destroyed by this damn snotty filthy rabble…I was infuriated and lost my patience, and when I lost it and turned towards them and shouted back “Go AWAY, leave me alone” and rushed forwards a few steps towards them, as I expected they all turned on their heels and ran like hell in the opposite direction – they are often quite afraid of Faranji! One poor kid, in blind panic turned and ran straight into a tree, reeled back howling and then took off again!

So the further away I got from the hospital, the fewer were the shouts and cries going up alerting the neighbourhood to my presence, till, after crossing a rickety wooden bridge over a near dry creek. I was walking past animals and kids and houses in almost blissful silence. People still said Hi as we passed on the track, or they said nothing and withdrew inside their gates to watch me wander by. The closer I got to the church the more enjoyable, even uplifting the walk became, and once I passed though the gates again it was so peaceful and quiet I felt almost as if I had come home. I found the guard and he embraced me like a long lost friend, and beamed from ear to ear nonstop as he looked back and forth at the several photos I gave him. I didn’t see the old nun but, with the help of another man who turned up with rudimentary English, asked the guard to give her the photos and the news about the eye surgeon. I wished I had bought my Kindle with me because it would have been so nice to linger under those trees in the late afternoon sun, read and rest for a while.



Days End

Back outside, not far from the church gate there was a collection of animals feeding on  leftover stalks of teff , most of which was stacked up in two huge piles. Standing with them in the warm sun were several men, so I went and stood with them too, and we watched the ox and the donkeys and mule, hardly talking, just enjoying the peace at the end of the day. A little over an hour later it was nearly dark as I got back to the flat and put the kettle on for a cup of tea. I felt relaxed and resored  by my walk and was looking forward to that cuppa, but I didn’t get to drink it till much later because the phone rang and Melkam said “Doctor there is one lady for ruptured uterus” 

 

(…to be continued)

Behaving like Animals

One things that’s really special about Ethiopia – well this part at least – and its probably true in many parts of the world but I have only observed it closely here – is the relationship between people and their animals. Back home animals that aren’t “pets” are wary of people – cows in a paddock for example will turn and stare if you walk past but if you approach them they mostly run off, as do sheep. Its very different here – cows, goats sheep mules and ponies are so used to people they wont even get up off the ground if they are sitting down and you approach them. Mostly of course they are not expecting a friendly rub, which is what they get from me – usually they are yelled at and wacked with a stick and you would think that kind of behaviour would make them want to keep well away from us but it doesn’t seem to. Today I picked up a frisky little lamb that was with half a dozen other sheep and gave it a cuddle - it didnt struggle and its mother didnt fret, and when I put it down it just hopped up the path to catch up to them.

I particularly like the donkeys – they are remarkably placid patient and hardworking, and the white circle around their eyes, their big ears, large head and skinny legs make them seem very cute to me. They can also be quite funny to watch – yesterday at the market I watched as a man arrived with a donkey loaded up with a huge sack of some sort of grain. The donkey stopped near a set of scales and the man unstrapped the sack and dragged it onto the scales, it was weighed and then there appeared to be a long negotiation about the price being offered. In the end the farmer wouldn’t sell, and shaking his head dragged the huge sack off the scales and then tried to get the donkey to move about three feet closer so he could load it back on again but the donkey wouldn’t budge. The man yelled at it and hit it with a stick and finally took hold of both its ears and leaned back and heaved with all his might but the donkey dug his little feet in and leaned the other way and didn’t move an inch. Next the farmer pushed the donkey at the shoulder to make it turn around and start walking but once it was facing the scales again it refused to go any closer. The man gave up and dragged the sack back and heaved it back on with the help of another, and then off the donkey trotted to another buyer. Sometimes 8 or 10 or more of them are all tied together, or at least tied to a common tree or lamp post and as they shuffle about become more and more entangled with one another, and that’s when they start to get cranky and do a sort of hop and kick back with their back legs at the donkey annoying them from behind, there will be a little ripple of kicks and starts and an occasional bray as that one reacts and alarms the one on its other side, the whole cluster readjusts and then they all stand still again, heads down like embarrassed children, nobody saying anything.

I have often seen that young black and white cow and wanted to get a photo of the incredible coat you can see in the photo above . Yesterday it appeared again as the light was fading and I quickly hurried across to the paddock where it was nibbling at teff stubble. I approached cautiously hoping it wouldn’t  wander away but  instead it came close and then sat down right in front of me!  And then some sheep pushed between me and it, and then a woman with her grandson came and sat nearby and indicated she wanted me to snap her! So there we all were, sheep cow and people in a friendly little cluster at the corner  of the field.

The friendliness of animals towards people here is something that I really like about this place. They seem almost forgiving of the hard lives that are forced on them, and I cant help feeling a kind of affection for them. Isnt it a disgrace that when people are behaving horribly they say they are behaving “like animals”? Animals aren’t polluting and destroying the planet, murdering each other in the name of religion or race, abusing their female members or making landmines and clusterbombs. They give tremendous help and support  with enormous patience and long suffering, to all the poor people over here. Animals don’t behave “like animals”  - only humans do. 

Going to Church

Google Earth View with a Church at the Top

If you look at the Google Earth image of the countryside surrounding Motta, you will notice mostly a vast patchwork of fields at different stages of the cycle of growing and harvesting Teff, great paddocks freshly ploughed showing the dense black earth, others green with a crop that looks like some sort of pea variety, and many dusty yellow with the stubble of teff, the mounds of it scattered about, and then the village itself. But there is one other feature that caught my eye – every so often scattered across the landscape when viewed from 2 or 3 kilometers up there is a dark green roughly circular spot with a silver dot in the centre. These are the sites of traditional Orthodox Christian Churches, each circular with a conical shiny iron roof and surrounded by bush that hasn’t ever been cleared, land that hasn’t ever been cultivated or disturbed, home I read to uniquely preserved ecology, quite apart from the church building itself, some of which around here are said to be over a century old.

Four Nuns outside St Mariams Church

Today I did something Ive wanted to do for ages, and went to that Church in the picture above with Shewaye showing the way. The Google Picture above was taken 6 years ago – since then the village has grown out towards the church so its not quite as separated from the town as it once was and its only about 3km from the hospital. At the gate we met some wonderful old Nuns –I think they are often old widows who dedicate the rest of their lives to the church, and they encouraged us to go through, though the place initially seemed deserted.

A Massive and beautiful old Tree

Inside, it was wonderfully quiet and cool in the shade of the huge old trees in which we saw birds nests and almost immediately a couple of bird species I hadn’t seen before. It was really quite magical in there, restful and calm hidden away from the noise and busy dust of the streets, almost like already being in Church, no hassling children yelling “Hi” and “You” at me incessantly, no headache inducing sun, no dung to watch out for on the path, just solitude and tranquillity



St Mariams

The Church itself was closed but there was an armed Guard and one further old Nun keeping an eye on the place. We “chatted” and as always here they were only too pleased to have their pictures taken. I promised the old nun I would find out when the eye Doctor would be returning to the hospital, as she appeared to have a cataract in at least one eye, and also to get her photo printed and bring it back to her in a few days. We wandered about under the trees and finally exited by the opposite gate.

Another Nun at St Mariams

 

The Cost of Living

The Shopping

Thursday was December 25^th but because Ethiopians believe Jesus’ birthday was December 29^th, which is monday, it was just another day at the Offiice. Saturday, as usual, was Market Day and just as in the West, the last big shopping day before xmas was really busy. Everyone from everywhere seemed to be crowded into the market, but there didn’t seem to be anything special to buy, just more sellers and more people buying, in preparation for Xmas when they can all break their month long fast and gorge themselves on eggs milk and meat. I bought eggs : 1 Birr each (6 cents) and to get them home intact placed straw around them in one of the little plastic bags that I carry to the market for that purpose. I also bought a kilo of tomatoes for 42 cents, a small cabbage for 12 cents, 6 small carrots for 12 cents, a nice beetroot for 12 cents, 6 bananas for 1 birr each, 3 small limes for 1 birr, and it was around 50 Birr ($3) for a kilo of macaroni, a kilo of rice, half a kilo of raw peanuts – which I hadn’t ever seen for sale before - and a small mound of a local hot spice. The most expensive item by far was a tin of New Zealand Milk Powder - called “Me and My”for 100 birr ($6). I have seen places where fresh cow milk can be bought but I am not too sure if it would be safe for me to drink – my guts hold up pretty well, and Ive eaten local food that’s been offered to be polite wondering if I would suffer for it and haven’t so far, but I think local milk might be pushing it.

By the time I got back to the flat I had been walking out in the really harsh hot sun for about three hours - I always wear a hat but you still get very hot and dry and thirsty. Sitting down I noticed I had a really bad headache and so I had a couple of glasses of cold orange flavoured water. Later I still had a headache, and then I started to wonder if I was coming down with something. I remembered when I was squeezing through the crowded market an old woman turned to her side and sneezed right in my face – and the other day I noticed I had forgotten to take my malaria tablets – I checked my pulse – it seemed ok – I wondered if they would be able to treat meningitis here, or what was that other disease I saw a young woman die of last year – relapsing fever? It was only 3 in the afternoon and I felt tired – maybe I should go to the hospital and ask them to screen me for Malaria ? I checked my pulse again – 78 – and had another drink then lay on my bed wondering what to do. I had never been worried about my health before, never. In the end I fell asleep, feeling anxious.

I was woken maybe an hour later by the phone ringing – it was a midwife “Doctor, cord prolapse patient is arrive” “Is the baby alive?” I said – “Yes, alive” she replied. “Ok I will come quickly” And forgetting about my headache, hurried across to maternity. In the west “Cord Prolapse” is one of the few reasons for what we used to call a “Crash Caesar” meaning you do a Caesar as fast as you possibly can because with cord prolapse the baby often dies very quickly- the problem is that the umbilical cord has fallen down in front of the baby and will get so squashed as the baby squeezes down the birth canal, that blood wont be able to flow through it bringing vital oxygen to the baby from the placenta – and without Oxygen the baby will quickly die. We had already had one case like this earlier but the baby had died before the mother arrived in the ward – her labour continued and she eventually delivered a dead baby and went home shortly after. The midwives said they wouldn’t show her the baby“for psychological reasons” – the same reasoning we use back home for doing exactly the opposite! And probably the correct behaviour in both cultures…

Prayer at the Church Gate

However this time the baby was still alive. We cant do “crash” caesars here – theyre only possible in big units that are staffed 24 hours a day – but as the baby was alive and the heartbeat was strong , by acting quickly it was certainly possible that we could save it. So everyone was called in, we prepared the woman for the operating theatre by taking blood, giving medication, inserting a catheter and an IV line, all the while  checking on the babies heart beat. In half an hour we were almost ready to take her down to the Theatre building next door, where my anaesthetist and the theatre staff were rapidly getting everything ready. All that needed to be done was for the woman to sign the consent form – her name was Misa – but she wouldn’t. She wanted to talk to her family who were outside – several came in, there were lots of words exchanged between staff and family and the patient, but no, they decided, better to let the baby die – she doesn’t want a caesarean. The heart beat was still strong, there was still time to get it out safely but no they were afraid Misa would die. Talking went on for some time – their minds were made up, the baby would have to die.

I recognised and understood their reasoning – hurrying across to Maternity when I was first called I was wishing it had died already because there were reasons why I didn’t really want to do a caesarean – for one thing, this was the young womans first pregnancy and there would be many more – and having numerous pregnancies after a caesarean creates some special risks, complications that could conceivably kill the mother. Secondly, even though she stated she was “Due” she had not received any antenatal care at all and we had no proof that this baby was really “Due” – it could be premature and if so, unlikely to survive whichever way it was born. I did a quick set of measurements with the ultrasound machine and the baby measured small, about  the size of a 6 weeks premature baby, meaning if correct it was unlikely to survive even if born alive – but it could have been a small and undersized baby only 1 or 2 weeks early – there was no way of being sure.  So a doubly bad outcome was possible – no live baby and a caesarean scar to complicate the whole of the rest of Misas childbearing future. The families’ reasoning was brutally logical.

 

I sent the theatre staff home and asked the midwives to try and be especially kind to Misa. Her first pregnancy was about to end in sorrow.

The Numbers

Here are the figures for the Global Calender year just finished, plus the numbers for the year before, 2011, and then for comparison, 2009 which was the last full calender year before the volunteers recruited by the Barbara May Foundation began arriving half way through 2010. What the figures clearly show is that Andrew Brownings vision, that having volunteer obstetricians here would save lives, was clearly correct. In 2009 over 60 women, at least one every week was dying, but since then even though significantly more women are coming to give birth in Motta, in the last two years only 9 have died. This is because we are now able to do caesareans for women in obstructed labour and for women with a ruptured uterus:

Outcomes  :  Mothers and Babies                                                                     Shegaw Motta District Hospital
	2009(Before BMF)	2011 1st Full year	2012 2nd Full year
Mothers admitted	738	1009	1034
Normal Birth	486	719	734   (70%)
Forceps & Vacuum	173     (26%)	189    (18%)	191   (18.5%)
Destructive Delivery	0	11	6
Caesarean Section	0	88     (8.7%)	111   (10.7%)
Transfers(A/N)	79       (9.3%)	0	1
Maternal Death	60   at least  (1:12, 8.1%)	5        (1:200)	4        (1:250)
Perinatal Deaths	Unreliably recorded	106    (10.5%)	79      (7.5%)

I looked back at the other figures Ive kept from 2011. In regard to uterine rupture, I was expecting to find fewer in 2012 - my hypothesis was that women with obstructed labour would come earlier as knowledge spread about the expanded service at Motta, and they would get here before the uterus had ruptured, but to my surprise the number had doubled between 2011 and 2012 to a total of 22, the opposite of what I was expecting. What does this mean I have been asking myself?  I think it might mean that because word is getting out that survival is possible,  more and more women in that dire situation are being brought in rather than allowed to remain at home and die. In 2009 and earlier the enormous effort required to bring such a sick woman from inaccessible rural areas achieved nothing – she died. Now there is hope!

Women Walking (Note men carrying nothing!)

My hypothesis that women might come earlier for help does have some support however, in the fact that Destructive deliveries have almost halved, from 11 to 6.  I realise one shouldn’t read too much into such small numbers, so it will be interesting to see what happens to that statistic this year. Destructive deliveries occur when the woman arrives with a dead baby that is stuck with a fully open birth canal, but the uterus hasn’t yet ruptured so the baby is “removed” without having to do a caesarean. If the woman had come earlier, when the  baby was still alive we would have done a caesarean. So if women were deciding to come earlier when runing into trouble we might expect to see fewer of these ghastly "destructive" deliveries, more caesareans and fewer perinatal deaths! 

And indeed that is what the stats show! Yes, we are doing more caessareans, there are fewer dead babies being delivered and fewer dead mothers - well OK, one! - as a result I hope of women realising there is help here if they get her soon enough!  Again, the numbers are not huge and all these stats may just reflect random fluctuations in outcomes, but a reduction in perinatal deaths from 10.5% to 7.5% if real, is a significant result. In the west perinatal deaths are often under 1%, and maternal deaths are something like 1:12,000 births, so theres still a long way to go.  
 

The other number I thought was interesting was that the big jump in the total number of  admissions between 2009 and 2011 didn’t happen again between 2011 and 2012. We know that something like 90% of women give birth at home in rural Ethiopia so there is still a massive catchment out there and we only assist a small fraction of it.  So why aren’t more continuing to pour in? I suspect the total number of women may not increase much more from here because most of the women who can come already do – the rest just live too far away to be able to get here. The reality of course is that the majority of women giving birth anywhere do it successfully and both mother and baby survive. However if the nearest road is a four hour trek along a narrow country track, and its nightime and there are no buses, and there is no ambulance to call and no phones even if there was one, by the time its realised that the birth is all going horribly wrong, its too late.

And by the way, I think Andrews next plan is get an ambulance.