Antenatal clinic & IUDs

I'm sitting atop our new mattress after a weekend in Blantyre and I could almost cry, it's so firm and back-supportive. We forgot to measure our old foam mattress, so as we visited different shops in search of the proper spring mattress, we had to lay down on each option to suss out if the sizing felt correct for our homemade wood frame. Hmm, does this seem the same as when Lev, Thea, and myself read together in the evenings? There's not straightforward sizing here: there are Chinese mattress sizes, and South African mattress sizes, both of which are not the same as American mattress sizes. There is nothing so humbling as laying flat on your back in a skirt and sandals, on a mattress lying on the asphalt just outside of an old warehouse, as a Pakistani businessman politely averts his eyes. We were inordinately pleased that we bought the correct one. 

"Once you have a spring again, there's no going back," two different people told us and I can believe it. 

The other best part of the weekend was the almond croissant we found at a bakery and shared together. Our first taste of almond since we moved here. Wonderful. 

The best we could do at a family selfie taken by Lev.

Tomorrow it's back to work. I plan to spend the day working at the antenatal clinic, which I've been doing 1-2 days a week for the past month or so. It took about two weeks after my midwifery license came through before the Matron asked me to start picking up shifts. This wasn't something I expected to do, because Malawi educates such large numbers of nurses and midwives. But the country is also in a severe economic crisis and the hospital is in a hiring freeze. The Maternal & Child Health team has been shortstaffed for over a year, having lost four midwives with no way to replace them. But I don't draw a salary - so they were eager to have another midwife to help out. Truth be told, I'm glad to have the chance. It's satifsying to get my hands on pregnant bellies again.

The antenatal clinic.

It's been fun to work with the MCH team, whose members I know pretty well from our work with the mobile outreach clinics. How prenatal appointments here work is: All the pregnant women - maybe sixty to eighty per day? - gather around 8 AM. They have to listen to a health talk given by a nurse in a big conference room, then they sing a song, then they all get weighed, then they run to the antenatal clinic to try to be first in line. They have to be exceedingly patient, first waiting for the two or three midwives on duty to take everyone's vitals, then again to be seen by a midwife for 5-10 minutes, then again for their health information to be entered - by hand - into a big registry book afterward. It is typical for a single prenatal appointment to take up their entire morning, plus whatever time it takes them to walk to and from the hospital. 

Patients sign or leave a thumbprint after receiving a mosquito net, which are provided free by the government.

Violet counting out iron tablets, another of our daily tasks.

I love going up and down the lines of waiting women taking their blood pressures. For one thing, they all smell like woodsmoke and the earthy body odor of women who work very hard at home. Sometimes the blood pressure cuff almost doesn't fit around their biceps, because they are so ripped and strong, despite being otherwise very lean (and with excellent blood pressures). Everyone sits quietly; there is almost no talking between them and they watch everything like a hawk. If I speak Chichewa I have to repeat it twice because (probably my accent is terrible and) they just don't expect those words to come out of my mouth. Then they giggle shyly and duck their heads, shifting their eyes downward. 

During the appointments, I work with another midwife who asks all the pertinent questions and documents the information in their health passports, while I do all the physical assessing of their pregnant bodies. I could tell you a lot about the various underclothing options for rural women here. I can tell you which cheap Chinese purse is the most popular (pink, with fake fur on the handle.) I've seen so many colorful, pretty chitenjes, I've had to restrain myself from offering to buy it off their bodies.

And guess what I've been using the whole time? A fetal doppler, baby! And guess what my coworkers now have access to, as I slowly train them how to use it? Fetal dopplers, baby! Working side by side seeing patients has been a wonderful way to demonstrate the benefits of a doppler, because they can see for themselves how we can pick up a heart rate in even very early pregnancies, at 11 or 12 weeks, and how quickly we can find it in further advanced pregnancies. Also,  my neck and ear don't hurt from bending over a fetoscope all morning, struggling to hear and count heartbeats with a timer.

Nalles learning doppler.

A fetoscope can be a fine option; but this is a case of simple technology being faster and much more accurate. It also prevents extra visits to the radiographer for an ultrasound, for those cases when the fetoscope simply can't pick up the heart rate but the doppler can, confirming viability. It is special to see the patient's eyes light up when she hears her baby's heart beating for the first time, once it has been explained to her what that staticky rhythmic noise is - just like it is special for women all the world over. "Mtima wa mwana," I say, smiling big, matching the baby's rhythm with my free hand resting over my own heart. "The baby's heart!" The wonder on their faces. It's the best feeling in the world. 

The patients range from 15 to 40 years old, with the majority being 18-24 years old - and an occasional thirteen year-old thrown in. They rarely have any questions about their pregnancies, other than to verify how far along they are, how many months left to go. They never mention common pregnancy discomforts like heartburn or nausea. The young ones are always a reason to rule-out that sexual abuse isn't going on at home or school. They're also heartbreaking because it means they have to drop out of school immediately, despite not having progressed past, say, fourth or fifth grade. "But why can't they keep going to school while pregnant?" I ask for the hundredth time, at which people laugh at me, not even trying to hide it. "No really, why can't they just stop when they go into labor?" More laughter. 

Two weeks ago I missed my normal day in the antenatal clinic to help out with a Sexual & Reproductive Health campaign in the villages, to promote long-term contraception. IUDs are an almost impossible sell here. Women prefer to come and get a Depo shot every three months, instead. This is an onerous form of child spacing, especially when many families hope to wait five years between children for economic reasons. (They see my two kids, who are just 20 months apart, as a clear sign of being an rich azungu. Sure, but I also didn't start till I was 35.) An IUD that lasts 5 or 7 or even 12 years would be such an easier, more failsafe, method for them... if they didn't think it caused cancer or made you permanently infertile. Those are the common myths about IUDs here. 

It was interesting to observe the planning for a weeklong sensitization campaign meant to promote implants and IUDs. The first day - the Launch, during which no services would be offered - was the most essential component, in order to generate "buzz". They did this in a way that no American would ever dream of doing it. 

First up: hire a local poet to compose an original work for the occasion. ("About IUDs?" I clarified. Yes. The cost of an original song about IUDs was deemed prohibitively high.) Also necessary: a drama group, traditional dancers, some testimonials, inviting the local chiefs to attend, inviting the district reproductive health officer to attend, and hiring "shouters" to drive around the villages with a loudspeaker to promote the event for three days. The budget got approved and away we went with it.  

The launch went well. We set up a tent in a busy area near a primary school. Because school had already been dismissed for the day, about two hundred little kids immediately gathered around us and started spontaneously dancing to the music we were playing as things got set up. Six to eight year-olds were not really our preferred demographic for IUD promotion, but many adults eventually gathered, too. 

Man... Malawian kids can dance!

It was a rousing success, as far as launches go. I had no idea what to expect, but the poet ended up performing something akin to a cross between slam poetry & a one-man show. His impressive "poem" lasted for over twenty minutes. At one point, he took off nearly all his clothes, to swelling roars of approval from the crowd, which grew to be about 15 people deep, gathered in a circle around the tent. Necks were craning. Curious bystanders sidled up to see the commotion.

He started off like this...

And ended up like this. It apparently made sense with what he was saying... about IUDs.

I had no idea what was going on, of course. I was sitting in a row behind the chiefs and - frankly - having the anthropological time of my life. All the local dignitaries present were introduced, including our small health team. I was about #23 in the lineup, at which I stood and waved like I was on a float in a small town parade. The whole thing was very fun to watch.

Unfortunately... the very next day it began to rain heavily and did not stop for six days. By the time it finally did, the campaign was long over. We had placed zero IUDs. 

People who walk for miles every day of their life don't go out in the rain, unless they absolutely cannot avoid it. They certainly don't go out to have a possibly cancer-causing IUD placed into their uterus. (To reiterate: that is a local myth, NOT true.)

We did place a couple of implants, though - which are good for three years.

So it goes. Such are the vagaries of development work. It often progresses exceedingly pa'ngono pa'ngono, as they say here: little by little, step by step.

Maybe one of those dancing six year-olds will have taken the IUD message to heart and, when they are grown, decide that reliable, safe, long-term contraception is the right choice for them. Rome wasn't built in a day. Neither is a very poor nation's sexual and reproductive health strengthened. The message sinks in over time.

Now I shall watch a movie with Matthew while sitting up on my firm new mattress, with no back discomfort present whatsoever, and dream sweetly tonight of that beautiful almond pastry. Gone but never forgotten. 

There was a very cool Tarzan tree at the bakery in Blantyre.