Sunday, April 12, 2015

Learning about labour and delivery through another culture

Gillian and I (Marissa) spent our week in maternity. We both came to Africa dreaming of the opportunity to deliver babies, and by 10 am on our first day this dream came true for both of us!! We were both very lucky to assist with a delivery each at the same time! Here is a photo of the two babes we helped deliver our first day. 


I was on an adrenaline high during the mamas labor. As I cheered on mama yelling "Kasha a hulu mama, kasha!!" (push mama, push!) I felt like I was on the field with my teammates, cheering and congratulating and expressing how proud I was. In this aspect I was in my element and I loved every minute of it. The delivery itself, however, was a completely new experience and I was overwhelmed with emotion. Helping a mother bring her new baby into the world is a feeling I don't even know how to begin to describe. Everyone always says birth is a "beautiful thing" and while I agree, it is also so much more than that. I felt privileged to be allowed to be present during this private moment of the mamas life, and transitioning a baby from his safe haven in utero to the real world was a surreal experience for me.


There were frequent deliveries this week and I got to witness the first few minutes of life for many different babies. I was also privy to the first moments of interaction between mama and baby. I try not to make constant comparisons between Canada and Zambia yet I couldn't help but observe the differences between how mama and babe bond in the two respective countries. We all either know or can imagine how a mother would react to her new baby in Canada. There's a lot of smiles, cooing, tears, and disbelief as a mother takes in her newborn for the first time. It is a beautiful thing to witness, and in my third year of nursing when I saw a mom lay eyes on her new baby girl for the first time I cried at the raw emotion and joy she expressed. My experience in Mongu was very different. After delivery the babies are immediately whisked away to the warmer where they are dried off and swaddled. They stay there and don't get returned to the mother until she is back in her bed on the ward. This startled me the first time I saw it occur so I started bringing the babies to the mamas to show them their new ones and give them a chance to attach because I assumed that's what they would want. It surprised me immensely when I realized the mamas weren't concerned that their babies weren't in their arms as soon as possible, unlike what I have seen in Canada. They were happy to lay eyes on the little ones, and I did see some big smiles and excitement when I brought them their babies. But this was short lived and after a minute or two they would lose focus and turn their attention back to something else. This frustrated me in the same way I was frustrated by the lack of bonding I noticed on post-natal, and I was befuddled by the way the mothers appeared slightly disengaged. It's not that the mothers don't care. I know they love their little ones. Yet I still noticed a lack of immediate attachment and expression of love as you would see at home and I had a hard time understanding the reasons for this. 
I have come to the realization that this way of being is a cultural difference due to the unfortunate reality of high infant mortality rates. According to UNICEF, in Zambia, there are 70 deaths per 1,000 live births. Even more shocking are the under 5 mortality rates, where there are 119 deaths per 1,000 live births. To put this in perspective, Canada's infant mortality rate is 5.1 deaths per 1,000 live births - and Canada's rates are actually quite poorly compared to other developed countries. As UNICEF puts it, Zambia's infant and child mortality rates are "unacceptably high." 
This week I learned that many mothers don't give their babies names right away because they know there is a chance their baby may not survive. I also learned from a local woman that children do not get funerals until after the age of 8 because child mortality is too high and it isn't feasible to have funerals for every child that is lost. This is an unfair reality that saddens me to my core. Many women I have met in Mongu have lost a child - it happens so often it seems that it is a common occurrence. All of this breaks my heart and I wish there was something I could do to change it. However, this knowledge has helped me understand a new aspect of the Zambian culture and shed light on the way mothers regard their babies. The women here are incredibly strong and the realities of losing a child have given them a very thick skin. I now realize that my perceptions were incorrect and what I perceived as being disengaged is in fact just a means of emotional survival in a harsh environment.

What amazed me (Gillian) in the labour and delivery room was the minimal amount of supplies and the minimal use of machinery in the room. When I witnessed a previous delivery at home in Canada, monitors were being used, IV's were running non stop, epidurals were administered for pain, vitals signs were taken frequently, oxygen was being delivered and all kinds of emergency equipment was available. In the labour and delivery room here in Mongu, there may or may not even be an IV running, oxytocin may be given and the emergency equipment is an ambu bag in case the baby is not breathing. Pain management is non-existent here and coping is left up to the mother. Sometimes the mothers may need blood, but that all depends if the blood bank has it available. Although some complications can arise, such as a postpartum hemorrhage, most of the care is determined by assessment and instinct alone rather than by a monitor. This is most likely due to the lack of equipment, however it has proven to me to be pretty effective throughout the deliveries I've seen during the week. For example, the doctor determined that the fetus was breeched right before the mother was able to deliver. In a situation like this in Canada, the woman would be rushed to the operating room for a cesarean. However, the doctor made the call to deliver in the birthing room. As the baby was being born, the doctor would not allow me to assist the mother nor was he going to send the mother to the operating room. Although the mother would have been a candidate for a cesarean (according to the WHO's article on performing cesareans only when medically necessary), it was the doctor's decision and certainty about his decision on the delivery that amazed me. He made an emergency decision with no equipment or assessment tools. After the delivery, the mother and babe were fine. One other thing I've learned through this is to trust your instinct a lot more and to remember how powerful our assessment skills can be. This experience has also been a nice reminder of the capacity women have in a natural child birth.


A humorous and creative moment for us was when Marissa and I had to mix a solution of ringers lactate and dextrose in a normal saline bag for a doctor's order. A baby who was born at 28 weeks (premature) had a doctors order for this mixture. Due to the lack of supplies, the only way the correct dose and correct fluid would be given is if we created our own. We used our sterile technique as best as we were taught to creatively mix the solution and hang it. Here is a photo down below of the solution we came up with according to the doctor's medication orders. 


I have learned that creativity is handy to have when working in Mongu! One day I will think back to this during my practice as a nurse in Canada and be amazed that this is what we did and that this is the reality of health care practice in Mongu. 


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