I think the time has come to talk all things Maternity. I still haven't seen a delivery yet, I'm waiting for a medical student to tag along with, but my daily trips to 'Bethlehem' have equipped me with the knowledge I need...
I don't have exact figures for the local area but my experience suggests that most mothers do not give birth at home. The first port of call (if no high risk factors are identified ante-natally) is the rural health centre where the midwives and clinical officers will assist with the delivery. For some women, St Francis' is their nearest centre and they will come in labour. If any rural health centre has any concerns then they will refer the lady to the hospital for treatment.
However, these are not the only ladies that the hospital treats by a long way. Ladies from further afield with a POH or BOH (Poor/Bad Obstetric History) or where there is some concern for the birth can come and wait to give birth. They are known as the Waiters and have their own accommodation block behind OPD. Here they stay for sometimes many weeks just waiting to go into labour. Then hey presto they waddle over :)
For women where the concern for their health is more acute, there are two bays of beds in the ward reserved for them and they get to sleep more comfortably until the day comes. The ward is a large open rectangle, bays are marked out by waist height walls only. So these ladies have to wait in a room with new born babies.... it's not exactly peaceful at times! And the showers at the far end seem to fill the ward with hot steamy air so it feels a bit like a rainforest in there at the moment.
When the woman is in fully developed labour she goes to the delivery suite. At home this would be a set of relatively large private rooms (yes, I have been watching one born every minute) where the woman and her relatives can pass the time. In SFH, there are no men (excl staff) in delivery and rarely on the ward. The suite is actually more like a corridor with bays coming off it, that have a bed and a chair in, but are completely open. Rather unthinkingly the first time I went looking for the delivery book I set off down the corridor only to see out of the corner of my eye that the first bay was occupied by a very naked lady - I averted my eyes and walked on quickly. Most women have their mums (I assume) with them on the ward, so I'm guessing the mums are also in delivery sometimes but I don't know this for sure yet. The process is done quietly - any shrieking is discouraged by the midwives so all that can really be heard is heavy breathing and some mild wailing. It's a bit eerie to listen to from the office as I collect info.
If the birth goes well the woman stays in delivery for about 2 hours before getting dressed, picking up her things and the baby and walking to the main ward. Yes, that is what I wrote. Very often she is sent home that day, carrying her things, with the baby in a chitenge on her back (or front or side).
Sometimes things don't go well. SFH delivered 3,176 live babies in 2011. Of these, nearly 700 had to go to SCBU (Special Care Baby Unit) and of those nearly 150 died. A further 192 were stillborn.
There is a 'myth' at home that giving birth is a natural process and therefore it must be relatively low risk and African ladies can do it alone safely. This turns out not to be true and the hospital lost 11 mothers last year. The Caesarean Section rate is over 25%, almost as high as in New Zealand (28%) and just above that of the UK...... In Holland it is c.6%.
Why is this? A number of reasons. Some C sections have to be done for reasons like the baby being breech or getting into distress. Without the detailed ante-natal care at home some complications that could perhaps have been picked up on are not found until the last moment and the mother's life is at risk pushing the emergency rate up a bit.
But, unlike at home, a lot of the sections are in relatively young women, by which I mean 14-22 years old. These girls have had some degree of malnourishment for their whole lives and are relatively small, they may not even have stopped growing - even at 22. So a normally sized baby just can't fit out through their hips...
And once you've had 1 c-section, the likelihood of your uterus rupturing if you try to give birth naturally the next time is higher, so some doctors like to be very cautious and swap them to c-sections for life. I'm reliably told that this is OK up to about 4 but becomes increasingly suspect after that point.
After a c-section the baby/babies (I've seen lots of twins!) and mum are kept in for 6 days. This isn't strictly necessary but the Consultant likes to give them a rest from home. When I collect data I can see how many children each lady has (and whether they are still alive). The most I've seen so far is 10 but over 5 is very common. Survival varies considerably, some ladies have had 10 children only for every single one to die. And some ladies had 10 and they all survived!!! Football team here we come!
I'll write a separate bit on breastfeeding because it's a whole topic in itself but it is encouraged immediately and can continue for a number of years from what I've seen! The ladies on the ward seem quite relaxed most of the time. Even when the babies are crying. They work methodically through - hungry, needs changing, cold/hot, needs a cuddle. If none of that works they just put the bundle back down again and carry on with what they are doing. I also often find the beds occupied solely by a baby swaddled in a chitenge or blanket with the mothers outside or in the shower room. It feels like a long way from the 24 hour attention advocated in the UK. Thou shalt never let baby cry or be out of your sight...
I imagine that having so many mothers so close together is a good way for new mums to learn the ropes - especially if their mum isn't there. But it has its downsides - specifically around privacy - there is none. The other day a baby started crying loudly on a bed. I looked over to see what the mum was doing and she was sat bolt upright on the bed staring away from it. She didn't look round or even seem to acknowledge the noise. After a few minutes another lady (too young to be her mum) came with a chitenge, swaddled the baby, picked it up and started giving it water off a spoon. Even your troubles with your baby are not private.
Before our trip away I went into the Maternity ward first thing - just after 7am - to collect the data from the night before, just in case the ladies had been discharged before our return. I could see the ward-round in progress, but thankfully they had cleared the first bay of beds where I was headed, so I sat down with the first set of notes. A high clear male voice filled the air, it was hard not to listen so I tuned in 'the baby was found motionless at 23.10. It was declared dead at 23.30' I looked up to see who was talking 'the other baby was moved to SCBU'. Throughout, the mother sat at the head end of her bed, facing away from the group at the foot end of the bed, staring into space. Even your grief must be shared...
But it's by no means all doom and gloom and I enjoy seeing the new babies all wrinkly being held so tightly by their mothers. And there is comedy to be had in OPD as well.
One particularly fraught and busy afternoon Rory called the next female patient:
Rory: what can I help you with?
Patient: I have swollen legs
Rory: anything else?
Patient: a swollen belly
Rory examines the patient
Rory: you know you are pregnant?
Patient: yes!
Rory: that probably explains the abdominal swelling? it will go down after you give birth....
Patient leaves
Next patient enters
Rory: how can I help you?
Patient: I want to have a baby...
I'll leave the rest to your imagination!
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