Diary of a Midwife: Uganda
by Marva Zohar

[Editor’s note: This article first appeared in Midwifery Today Issue 94, Summer 2010.]

In the five years since I began working in the birth field, first as a doula in Israel and then as a midwifery student in the US, I had not yet seen a dead baby or a dead mother. And yet, here in Uganda, I have seen both in less than a week.

Sunday

That moment before it all happened, when the curtains between the beds in the labor ward were open and the two mothers stared into each others eyes, could they have seen then their shared fate?

I arrived in the morning. Sister Mary said, “We have heard no FHT, but we shall not cut because we do not know for sure and we shall not cut a woman for nothing.” She and the doctor went for rounds and Sally and I stayed with the two laboring mothers. I heard a definite swooshing of placenta pulse down low—much too low—in the abdomen. My woman was named Sarah. Sally was tending to the other woman, the one who did not speak any common language, and we were not even sure of her name.

At crowning, as the head was emerging, I reached for the umbilical cord; it lay between my fingers like a cold wire with no pulse. I had been hoping the fetal heart was just hiding behind the placenta, but now this pulse-less cord. I looked at Sally but she (a young midwife, no older than me) said, “It’s okay, you have nothing to do.” So I received the stillborn baby into my hands.

The other baby, born to the mother in Sally’s care, had been dead for a while, the skin was peeling and the placenta came out in fractions, only with manual separation.

When Sarah, the young mother I attended, was deep into labor, she mumbled in Lugandan, her mother tongue from her early years. Sally, the midwife, translated for me. “I feel like I have malaria,” Sarah said. But, when she was mourning her dead baby, she cried out in English, as if her query was directed at me, “Why? Why?” She looked from my eyes to the eyelashes of her perfect baby girl. I held her, we cried together, but why? This woman was not poor like some others, she was not malnourished, she did not have the sunken-in eyes and cheeks of the woman in the bed next to her. The woman in the bed next to her had walked into our ward from the bush; she came in at 8 cm dilated, with no prenatal care and nothing but the dress she was wearing.

Sarah had seen us throughout her pregnancy; she had a suitcase well-equipped with gloves, the black plastic cover the women are supposed to bring to cover their beds. She brought gloves and cotton, she spoke good English.

What was the cause of death? FHT were heard (according to the night staff’s chart, which was not perfect, but still responsible) at 10 pm, but at midnight they were not found and some vaginal bleeding was reported. I do not know when or how much. Later in the night I read about placenta previa and if I had to guess the reason for the death I would quote this paragraph “…is associated with an unexplained…fetal demise.” But I did not have to guess the cause of death, because no one had to account for it. Sarah asked me, “If I had had the scan yesterday, would my baby have lived?” This is likely, I thought, but I said to her that I did not know.

Sarah was counting the fingers and toes of her dead daughter.

“Sarah,” I said. “I’m so sorry, but I need you to push out your placenta.” For the longest time there was no response. Then, “I am weak, I have no strength.”

 “I know,” I told her. “You have worked so hard, but you are strong and you will have many more healthy babies and you need to finish, you need to focus on bringing it out.” This seemed to work, she looked at me and nodded, still she had no contractions.

But the other woman’s baby was coming and Sarah looked toward the other bed, where Sally was lifting the baby from its feet, but there was no life. We all stood there for a moment—but it had been too long and Sarah’s placenta needed to come out.

It was Sally who guarded Sarah’s uterus and pulled out her huge placenta. I read about this later on and thought the placenta may have been so large that it overlapped the cervix.

But the other woman, she had no more strength. The doctor had to go in for a manual placenta removal. He was asking for the long cuff gloves, but there were none.

Would I have been able to go into a woman’s uterus to extract that fragmented placenta without long gloves?

“She has been tested?” he asked very quietly. “Yes, she is negative,” was the answer, but his hands were already in when he asked. I had come to trust this young doctor. Once, when we had a difference of opinion, I had said to him, “You are the doctor.” He replied, “I am a doctor, but I am not God.”

The water and power were out, so I went to the volunteer house to wash my hands, use the toilet and, I confess with some regret, to get a bite to eat. I say regret because by the time I came back to the hospital Sarah and her family were gone. But with the questionable sterility of the instruments and the field, the fresh sutures, the breasts that would be engorged without relief, I wished she would have stayed for at least a course of antibiotics.

The other woman, the one with the scars all over her body, would stay. She had lost too much blood, had suffered the pain of a manual removal and everything about her face screamed “hunger.” She had a vertical scar along her fundus, another one along her chest, and many bruises and scars like stab wounds all along her legs. They were asking for a box, for the baby. After a long search, I found a box with some art supplies that Elisabeth—the German volunteer—had gathered to use with the children. I took the colored pencils and papers out of the box.

On the grass, under a pile of clothes, was the baby, but a woman who didn’t speak any English was trying to tell me not to put the baby in the box. Finally, a staff member came and translated; the box was intended for the other family; they were inside. I found their baby by the sink where we leave the instruments to dry, placed her in the box and covered her in the cloth.

Now I think I could have done a better job cleaning her, but the only thing I had to use was cotton, and cotton sticks to anything moist, leaving white fibers all over, so I thought it was a better sight to leave the baby as she was, even covered in thick meconium, vernix and blood.

The baby made me wish I had looked more closely at the color photos of different anomalies in my fetal development and genetic books. Back then, when I was doing those academic courses, I skimmed through these almost pornographic photos. But there was nothing horrific about the perfect body on the table. Her skin was peeling like a peach, revealing a soft pink layer, indicating this baby had been dead for some time. “Two to three days,” Sally said, with a confidence that testified to her familiarity with the riddle of little dead bodies.

The eyes were slightly slanted and the head molded with an extremely long occiput. But was this a congenital anomaly or simply a baby stuck for days in the birth canal? Again, no explanation was given.

Monday

I stayed away from the hospital. Instead, I spent a wonderful day with the women from the Shanti Uganda income-generating group, dancing and beading and singing.

Tuesday Morning

This morning there was the unmistakable smell of a corpse in the clinic. Unmistakable, even though I had never smelled it before.

A mother had died during the night from placenta previa. “She came in with no FHT, the bleeding was too much,” said Jonah, who had braved the night shift by himself. By the time they realized what was happening, it was too late to operate and she had lost too much blood.

“We cleaned the body,” Jonah said. “But they will get the baby out. It is not their custom to put them in the ground with the baby still inside.”

First I saw only the legs splayed to the sides of the bed, and the curtain. It was better to see the whole body, to see the peace of her, the perfect corpse pose, with the very small pregnant belly, and the breasts poking up, ready with milk.

Outside, the family was sobbing. Tuesday is vaccination day and many mothers were coming in with their infants. Later, I asked for the details. Sister Mary was not her usual self. “The maternity should not be such a sad place,” she said. The woman had come in from the nearby, more rural clinic in the village of Kasana. She had some bleeding and FHT were “unclear” when she arrived at 8 pm. She wasn’t checked again until 4 am. Jonah had been busy with another labor, a c-section, as well as looking after the medication rounds and the post-labor ward. The woman left seven children and a husband behind and all of them were in the hall sobbing. It seemed very cruel to mop the blood between their feet.

Tuesday Night

I wake up from a dream about the dead mother. I won’t call it a nightmare because I do not jump out of sleep in a cold sweat. This awakening is slow and silent, like neglect. Like coming to the hospital at 8 pm and not being checked again until 4 am. So the dream that woke me was not a crash into horror, it was the slow trickle of blood, the minutes creeping by, the many things that could have been done. Time of death was 7 am.

Wednesday Afternoon

It is good to focus on the planning of our birth center. I am in Kampala now, coming back from a tour of two birth centers in nearby districts. After my crash course in African reality, my reasons for coming here are stronger and clearer. To choose to do what is possible, despite the temptation to fight the emergencies day and night, not to allow the staff to face the night shift alone ... I realize how important it is to work toward preventing these cases from ever coming to such close calls.

Allow me to look back now at something my teacher had said when I was studying in Taos, New Mexico. One night we were resting on the sofa, in the wee hours, as our laboring mother was dozing into sleep. And my teacher was telling us about a letter she received from a prospective student who had visited another clinic and was not satisfied with what she saw there. The student was looking for a midwife who “trusted birth.”

“I hope she will not be disappointed,” my teacher said. “Because I do not trust in birth. I just don’t.” I was fresh out of an all-natural doula course and as my teacher spoke these words she might as well have grown red horns and a tail before my eyes. What did she mean, she didn’t trust birth?

“I don’t trust birth. I trust in midwifery,” she explained. “I trust my knowledge and my skills. Things happen, birth is dangerous. That is why, in countries where they don’t have access to care, things go wrong all the time.”

Now I understand what she was talking about. Teacher (I think you know who you are), please accept my apology.

Saying you trust birth and therefore there is no need for any care during pregnancy and birth is the same as saying, “I trust life so I will not feed my child nor teach my child how to cross the street.” Birth is safe because women are meant to give birth, but it is also safe because of the conditions in which we live and because of the combined wisdom of medicine and traditional midwifery. Any battle between the two is pointless. It is a fine balance between wanting to save mothers and thinking they are not able and strong.

Recovery in Uganda

Recovery is a universal gesture. You will find it wherever you find life.

The first time I witnessed it was with one of my goats, back home in the mountains of Jerusalem. She had been attacked by dogs and lost her pregnancy. For nearly two weeks she just stood there, refusing food and water, the green flies swarming around her wounds as if she was already dead. We had to force her mouth open and spray syringes of water through her lips. But she wouldn’t even go through the trouble of swallowing, and most of the fluid would drain right out between her clenched teeth.

And then one morning it was there, with no sign hinting at it the day before: recovery. The will to live, the spark in the eye, the appetite. And from the moment she had decided to live, there was no stopping her.

It was exactly the same with Grace. Each morning, for many days, my eyes met her gaze, which had not moved from the floor just below her bed. She did not avoid my eyes, but looked right at me. It was like some sort of staring contest; she would always win because she had death and despair on her side, while I had only the frailness of hope.

Grace had delivered Jacob at her home in the village; then she started bleeding. She had sent her husband for help with some money she had saved for “when the baby comes,” but he took the money and went to the pub. By the time he got back, she was in between worlds. Now he brought her in, on a boda boda, a motorcycle. How a woman in shock and a septic baby can ride on the back of a motorcycle is still a mystery to me, even though you see amazing things being transported by motorcycles here, like 60 pineapples or a full-size sofa.

The sisters baptized Jacob because it didn’t look like he would make it through the night. But in the morning he was wide awake, sucking his wrinkly fist. He even nursed, but his fever was going up and down and he was grunting, his ribs retracting so deep I thought they might turn inside out.

There is no oxygen tank in the clinic. It is more than an hour away to the hospital where they have a tank. We explained to Grace that her baby needed oxygen. Grace looked at her baby, stroking his hands. Her husband said, “We have no money,” in a very sad way that made you think maybe he really saw no connection between the money gone to the pub and the helpless situation of his family.

The staff moved away from the bed and there was no further discussion. In moments like this, my Western mind is utterly lost. It runs full force on neutral, and the fact that everyone else sees nothing wrong with the situation forces me to step outside, lean on a mango tree and take some breaths before I can be part of it all again.

I fought for Jacob, and I convinced myself that he could live, first because of what Sally, the midwife, had said: he was strong, he had survived the night. “Mostly, boys are not strong,” she said. “Girls, you can bring them back, but the boys, once they are gone, they won’t come back.” Then my conviction grew stronger because there were entire clusters of minutes when he seemed fine. The temperature would go down, and respirations were within normal range, even if they were shallow.

But we lost Jacob and Grace said nothing. She made no sound, had no expression.

A week later, the staff forced Grace to eat. Threatening her with tube feeding usually got her to put a few spoonfuls in her mouth.

But then one morning it was there: recovery. She was sitting up in her bed, eating. You could tell she tasted the food, and then she looked at me and smiled.

The next day Grace went back home, to her husband and village. But just as she left, another woman who had delivered at home came in. The baby had been in the ward for hours before Anna, one of the German volunteers, took her temperature and discovered it was 40 degrees Celsius [104 degrees Fahrenheit]. She gave drugs to bring her fever down and had written in the chart to take her temperature during the night, but when I came at midnight no one had taken it yet. The baby was about as yellow as a banana peel but no one had facilitated giving her milk or putting her in the sun.

We talked over dinner at the volunteer house, about how when the system is so damaged and the need is so great, burnout will come, even if you have just started your career.

“You see the same thing with social workers, back home,” one of the volunteers noted.

I suppose you can only care about so many babies and have so many of them die in front of you before you keep away from those beds. It was as if they were marked for death from the moment they came, so no one wasted time or drugs on them.

Then there was the spina bifida baby; he stayed in the ward for a week, the family not able to afford the ride to the city or the cost of the operation to close the spine. They left him at the hospital, unable to cover the bills.

To know death is coming, to just wait, to ask all the questions you know have no answers—this is a part of daily life here.

The government hospital is supposed to be free, but it is so full of people waiting that you have to pay good money just to be seen by anyone. Then, if they operate on you, they can charge whatever they want because there is no fixed price for an operation.

In the night, my frustration was starting to let go of me; this baby is going to die, but at least he doesn’t have to die alone. He can be held. I picked him up and he looked right at me, and then turned to my apron pocket looking for milk.

Later that night a young girl came in an ambulance; she was sick in her head, the people were whispering. She had been raped and left with this baby inside her, someone explained to me.

Somehow the baby was born out of the screaming body. I couldn’t tell if the girl was always like this or if she was simply in shock.

She was sleeping on a mat on the floor; her baby, a 2 kilo [4 lb] girl with clubbed fingers and feet, was on the bed.

The next day I came to wake the girl to try and get her to nurse her baby, but Sister stopped me as if I was about to jump into running traffic. Sister herself woke her, and the girl tried for a little while to give the baby suck, but soon was distracted. It was clear that when this young mother went home her baby would not be getting any food.

No one to call, nothing to say, just wait.

Tessa came in on Tuesday. A small woman, with a very round belly, she had two previous scars and was awaiting her third c-section. At 11 am, she was 4 cm and the doctor was planning to operate before lunch.

She leaned up from the bed and whispered something into the nurse’s ear, which the nurse whispered into the doctor’s ear. Tessa wanted her tubes tied.

“Where is your husband?” the doctor asked Tessa.

“He is coming,” she said.

So now we were waiting for the husband to come and give his consent.

“I see the way you look,” the doctor said to me in the office. “You are unhappy.”

My poker face still needs practice. “It is her body, so why do you need her husband to agree?” I asked him.

“It is her body but they are a couple and, here in Uganda, if I do it and he sues me then he will win.”

So we all went for lunch and later that afternoon, when the husband came, he said no to the operation. Now Tessa was already 10 cm and she ended up pushing the baby out on the operation table. There was a lot of meconium and distress. The baby died the next day.

I cannot say that if the operation had been done sooner the baby would have lived. The medical information was not clear. But early that morning FHT were sounding good, promising.

The cause for the previous two operations was cephalopelvic disproportion but this baby, with his big round head, came out weighing 3 kilos [6-1/2 lb], almost without difficulty.

Feedback

Monsoon comes and washes everything away, turning off the white and grey smoke signals of the everlasting garbage fires. We have been touring different birth centers, trying to learn what they do here with the garbage, syringes and medical waste.

So far, each birth house we have seen has large cement pits where they dispose of needles and placentas—what you can not burn, you bury. When one pit fills up, they dig another and over time the land surrounding the clinic is full of cement graves. 

I am reminded of a permaculture course I sat in on at The Farm in Tennessee. The teacher talked all afternoon about the principle of feedback. Basically, this means that you will respond to what you see: if the water you use goes out to your garden, you will not be using an unfriendly soap once you see yucky white foam building up on your flower beds. But if that same water goes down the drain, you will never think of it again.

Part of what was so appealing to me about the Shanti Uganda birth house project was the fact that it was going to be an eco-friendly birth house. Now I am starting to think there is no such thing. In the West we have trucks that come to collect our biohazard waste; our trash cans full of chux pads and gloves, our sharps containers. We don’t need to think of it again. But what happens to all that stuff after the truck goes away?

In Uganda, no one collects anything; there are no garbage trucks and no hearses. You bury your own dead, you burn your own garbage, and you feed your mentally ill family member as best as you can.

Empowerment and Freedom Are Universal

I spent a day at the building site, pressing mud with my toes the way you press on grapes to make wine. I sculpted some mud roots and branches around the benches of the prenatal room. At the community meeting, the women had decided to come and help, working at the birth center and its outside grounds each Wednesday, forever. This was Wednesday and there they were, turning the soil for our garden where we hope to grow some food for the pregnant mamas.

One beautiful grandmother came, smiling without teeth, carrying a shovel over her shoulder. She said she was 80 or 90 and would come forever, even when she was no longer able to walk.

I was just back from our first meeting with the local traditional midwives. The beginning was slow—the lack of common language coming between us—and despite the heat of the day, two of the midwives, Bukiwa and Kasifa, had walked two hours in the sun to come and meet with us. Then a strange, uncomfortable power dynamic took over, widening the gap between us as many of the traditional midwives, asking for jobs, described their hardships and responsibilities.

When Bukiwa introduced herself she added the word widow, as if it were her last name. These women each had nine or 10 children and no jobs since the hospitals had put them out of business. Their legality was also in question.

Slowly, however, the magic of connection emerged. They described the trainings they had attended where they were told to “cook” the instruments—the scissors and the cotton they used for cutting the cord. One of them pulled out a plant from her bag, showing with her hands how she uses it as a tea to give the mother strength to push the baby out.

We walked to the building site; just yesterday the interior walls were marked enough so that you could see the rooms now—the bathroom, the room we will use for cleaning and cooking the instruments.

We had designed a sort of dent in the cement where a mother could squat and took them there to demonstrate a supported squat.

“You will have to retrain us,” Nanchinga said, “We were taught another way.” And she lay down on the fresh cement, among the tiles, the men building around us, and demonstrated a delivery in exaggerated lithotomy position.

“But is this new or old?” we asked. “Maybe your mother and grandmother used this way?” Nunchinga had said earlier she was trained by her grandmother, at a very young age, and Kasifa by her mother.

Kasifa confirmed this, her mother used this way she said, demonstrating a partial kneel-partial squat position.

This made them very happy. Soon they were trying out different positions, shaking our hands, saying thank you, you have done a good job!

The builders tried to ignore our joy—to avoid looking at all of us trying out birth poses—laying the bricks and stirring the cement, until finally one of them said, “Excuse me madams, you are disturbing the work.”

By now the laughter was coming from deep in our bellies. I suppose you don’t have to have awareness of the politics of birth, you don’t need to know the philosophy of the active birth movement, to feel the joy, the empowerment of giving women their freedom. Like recovery, empowerment and freedom are universal gestures.

Marva Zohar was born and raised in Nataf, Israel near Jerusalem. She studied midwifery at the Northern NM Birth Center (formally the Northern NM Midwifery Center) and with the National College of Midwifery. Currently she is volunteering in various communities throughout Uganda where she is working as a midwife as well as training and learning from local, traditional midwives.


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