Thursday, November 7, 2013

MGH/MRRH OB/GYN Collaboration: Mbarara Uganda (Sep-Oct 2013)

I can’t say that I was shocked when I got to Mbarara Regional Referral Hospital.  I had been there before, so to speak,  only in a different country on the opposite side of the continent. I knew the stark and dramatic differences. I was however taken aback yet again. It was hard not to compare what I trained in and knew well with what I faced in Mbarara. At MGH we have 11 delivery rooms, each private, with large beds equipped with movable and removable parts. These accommodate 3000 deliveries a year. At MRRH they have 2 delivery beds. Simple steel frames with a thin black pad. 

Delivery bed on the Labour Ward at MRRH

These 2 beds take the hospital through over 8000 deliveries a year.  This most basic difference in physical resources is only just the beginning. In almost every aspect of patient care and management the residents and obstetricians at MRRH make do with so much less – almost zero nursing support, limited supply of drugs and equipment, limited antenatal records, often no dating of pregnancies, no electronic fetal monitoring, limited availability of neonatal resuscitation, limited or no oxygen. This list goes on and on.

Despite the limitations of medical care and lack of – almost everything physical, I have been most impressed by the abundance of fortitude and patience displayed by the women seeking obstetric care at MRRH. After a cesarean section, women simply get on with the necessities of life with very little support. To begin with, they get an astonishingly limited amount of pain medication. At MGH women routinely receive IV toradal, shortly followed by regular doses of oxycodone or dilaudid, which they not only have throughout their hospital stay, but also go home with. Here at MRRH, it is a dose or two of pethidine (demerol) immediately post op, and then rectal diclofenac as needed. That’s it, and no complaints - they just deal with it.  They go to the bathroom themselves, empty their foleys themselves, , provide for their own meals, own sheets, and own supplies as needed.  They get only the basics from the hospital – a “Mama Kit” which includes: a bar of soap, 2 plastic sheets (on which they have their vaginal exams and on which they deliver), a roll of cotton wool (which become their pads), 2 packs of gauze, 2 razor blades, and a health card for their child. 

Mama Kit Provided to Patients on Admission
On top of that, their recovery is far from comfortable.  In a postnatal ward built to accommodate 30 women, there are often as many as 60. When the beds run out, which they always do, women, post vaginal delivery or some even post-cesarean get a mat pad and make a space on the floor – either squeezed in between two beds or at the foot of the beds. This happens every day. In the time I have been here I have never seen any woman complain, argue or express the slightest irritation at being placed on the floor. If they are asked to move to allow a doctor or nurse to get to a patient or a piece of equipment, again no frustration or complaints they simply pick up their mats, their personal belongings and their babies and move.

Postnatal Ward at MRRH

Without a doubt these women display extra-ordinary fortitude in coping with their physical pain and in managing without many of the comforts and support that women in Boston taken for granted. Perhaps even more remarkable is the resilience shown by a significant portion of these women  recovering from a neonatal loss, or delivery of a stillborn child. At this hospital the stillbirth rate has ranged from over 2-6% of deliveries. That is as many as 58 stillbirths per month, with over half of those often occurring intrapartum. Women who have suffered these losses also simply go on, also squeezed into the postpartum ward, perhaps next to, or in between women who are fortunate enough to have their babies well and crying at their sides. Their expressions and demeanor often reveal little and it is so easy to walk past them, or even examine and assess them without recognizing or acknowledging their loss.

 On rounds one day I attempted to ask a woman where her baby was. I was with a resident from India and we both could not communicate well. The woman lying next to her listened to our fumbled attempts, and took pity on us.  She could speak English –“the baby is in the Toto ward” (pediatric ward), she said quite simply, “they’ve taken it for testing”.  We thanked her and continued with our assessment of that patient. About 5 minutes later we got to the woman who had helped us. She also had no baby. We asked and she said – her baby didn’t make it. It was born alive and died shortly afterwards. From our conversation 5 minutes earlier I would never have known. For this woman, I had the opportunity to acknowledge her loss, and express some amount of empathy – though from where I stood I clearly had no concept of how she really felt. I wondered how many other women I had walked past or assessed without any recognition or acknowledgement of their loss. Knowing the stillbirth and neonatal rates, that I had done so was a certainty. 

Adeline Boatin
OB/GYN Global Health Fellow

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