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“Sometimes You Have to Just Walk Away…”

There is a particular statement that I have heard on Labor & Delivery units — not just on one, but on every single unit where I’ve attended women’s births. I have heard it from nurses, I have heard it from OBs and anesthesiologists, I’ve even heard it from midwives.

What happens before the statement is made is that a woman is laboring. She is in pain, and she is doing something to express that pain: perhaps she is calling to her family members for help; perhaps she is unable to keep still in the bed, causing the fetal heart monitor to fall off. Perhaps she is saying over and over that she can’t get comfortable, or begging to be allowed up out of bed to walk, although she will not be allowed to because of her epidural. She may be asking why she is still in pain despite the fact that she had an epidural. She may be loudly vocalizing her contractions — she may be screaming as they occur. Perhaps she has been doing some combination of these things for hours.

The nurse has wandered in and out of the room and said that the woman can’t possibly be in that much pain at only 4 centimeters dilated. The anesthesiologist has been called in and swears that the epidural is in correctly and that the woman is just feeling pressure, not pain. The midwife, shame on her, has stood three feet from the woman’s bed and said that she can ask the anesthesiologist to replace the epidural catheter, if that’s what the woman would like.

Everyone clears out into the hallway, leaving the woman alone in her room. And then someone turns and says to me, the student, as if offering some great wisdom: “Sometimes you have to just walk away and then she’ll calm down.”

I am recording this here because this statement should never become normal or acceptable to me, no matter how nonchalantly it is said, no matter how reasonably intentioned the person who says it. Bear in mind that I don’t mean a situation where a woman asks for privacy to labor (privacy being something that she will never get in a hospital), but rather one in which the clinician judges that the woman would be better off by herself.

The assumption behind this statement is, first and foremost, that the woman will essentially be alone in her labor. There is no expectation that she should be continuously supported throughout labor (as has been shown over and over again in research to lead to the best outcomes), no expectation that one should do anything other than spend a few minutes at a time dealing with her.

This statement also represents the feeling that a woman asking for help in labor is, after a certain point, just a complaining, attention-seeking, pain in the ass. Her pain, discomfort, or distress isn’t real — especially if you already gave her medication. She’s just being melodramatic, and what she really needs is for you to ignore her a little bit so that she can spend some time alone in her room. Like a child. You acknowledge that the woman is having anxiety and frustration — and your reaction is to walk out.

I have recently had the realization that the people who make this statement are also fundamentally ignorant — despite being professionally involved with women giving birth, they have almost no idea how to comfort them, calm them, and make them feel cared for. It’s not exactly their fault; most clinicians have lots of patients and are taught to use very few tools to relieve suffering apart from epidural anesthesia. Nevertheless, it is galling to see that this is apparently good enough for them, and that they consider it natural not just for women to be in pain in labor, but to suffer deeply as well. (The difference between these things is a topic for another time, but sufficed to say that they do not have to go hand in hand.)

Finally, this statement begs an obvious question: If you’ve left the room entirely, returning only hours later or when she shouts loudly that she is going to push the baby out right now so you’d better get in here, how on earth would you know if you helped her to calm down?! You left her alone, you fool — you have no idea whether she is curled up in a knot of suffering, or whether she’s actually glad to be rid of your ham-fisted, anxiety-provoking presence.

I know that there are some future midwives reading this post, so my reminder to all of us is this: the next time you hear someone offer you this particular “wisdom”,  remember that a gentle hand, a low voice, and a calm, steady presence can be the difference between a happy, healthy birth and a violent, traumatic one. Go back into the room and stay with her.

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What to Do If Your Blog Goes Viral: 10 Tips

When my blog went viral because of the fake Apple store post, I was totally caught off guard and made a lot of mistakes. I know it’s all very exciting when this happens and people start contacting you from all over the world, but it pays in the long run to be hardheaded about this in advance. Below are a few pieces of friendly advice based on my experience, in case going viral ever happens to you.

Please add your own tips on this in the comments section!

  1. Recognize what’s coming. Have 1,000 people visited your blog in the past hour, when previously only 10 people came in a day? Is your content being rapidly Tweeted? Welcome to the land of the viral internet! Prepare to take action.
  2. Decide what you want out of this experience. Are you looking to become famous on the internet? A full-time blogger? The next Paris Hilton? Or are you looking to maintain your privacy and your regular life? This will inform how and where you allow your content to be distributed.
  3. Consider buying the domain name of your blog address (e.g. for myblog.wordpress.com, buy myblog.com).
  4. Consider putting up ads on your blog. You may find this tacky, but when you realize that your content is spreading all over the internet and lots of people are making money off of it, you may feel differently.
  5. Make sure you have a copyright notice prominently displayed. Decide on a policy of how your content can be used by different media outlets (e.g. blogs, print media, television). Be aware that US law does not recognize the “moral right of attribution” – that is, just because you ask to be publicly credited when you give permission for your content to be reproduced elsewhere, doesn’t mean the outlet has to credit you. You having given permission for use of your content is enough for them to run it.
  6. Consider watermarking all of your photos, or disabling the ability of others to download/right-click your content if you want to maintain strict control (this may or may not be easily done, depending on who is hosting your blog).
  7. Realize that your content may have considerable financial value – don’t just give it away to people who are going to be making money from it. (Remember: multibillion-dollar media conglomerates are not your friends.) In particular, demand in advance that you be remunerated for any use of your content in print or on TV. Technically, there’s no difference in terms of copyright violation online/on TV/in print if your content is used without your permission, but there’s something particularly galling about not being paid for your content to be used in print or on TV by someone else. May them pay up.
  8. If you give permission for your content to be reproduced, do so in a limited way – BE EXPLICIT. For example: “Yes, you have the right to use this one particular photo for this one particular article, and nowhere else. You may not archive my content for future use.”
  9. Do not ever give permission for your photos to be freely used by a major warehouse of photos like Agence France-Presse (AFP), Getty Images, or the Associated Press (AP). These places have tens of thousands of clients, who will be buying your photos from them, without any financial gain for you. Your photos will be reproduced by numerous outlets credited only AFP/Getty/AP, without crediting you. AFP/Getty/AP will claim that they have no control over this – while this may be true, it will not help ease your feeling that very bad things should happen to these people. Giving your photos to one of these agencies will mark the end of your control over your photos – BEWARE.
  10. Do not be impressed or intimidated by your unauthorized content showing up in prominent places – get on the phone or send them an email and make sure they remove your content or pay your for it – or both. The following outlets are among the numerous places that abused the content of this blog: NYTimes.com, CBS News, New York Post, The Independent (UK), Le Figaro (France), and USA Today. I AM NOT IMPRESSED.

Anyone got anything else to add?

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Experience Overload Part 4: Danger in the Valley, and Making it Out

Barbara and I made it out of the Valley without incident, which is certainly not always a given. Last time we made our 5am exit (I kind of love doing that – stealing away under cover of darkness!) there was a giant mudslide following a night of torrential rain, and it looked like we wouldn’t be able to leave at all.

Before going to the Valley I had never encountered a mudslide and didn’t understand what the big deal was. So it’s some mud, right? Can’t you just…go over it? No, it’s not just “some mud” – it’s like a giant flood of rocky pea soup, up to your knees, or waist, or higher. You do not just “go over it”. Earlier this year, farther up the Valley, there was a mudslide that killed 30 people when it submerged an entire village – so don’t mess around with mudslides.

Life is full of little horrors like that in the Valley. It is a deeply beautiful place, and one in which life has become easier for the Azu over the past couple decades as they have become wealthier. On this past trip, all of the fields were ripe and bursting with greenery – mostly corn and rice, but there are also little orchards of peaches and apples,  and fields of tea bushes.

The Valley in April, when the rice was just starting to come up.

But the beauty and increasing fortune of Valley life belie the many dangers of living there.

The River that cuts through the Valley is a beast – broad and muddy, swirling with rapids and hidden boulders. Every year some number of people are carried off in it and drowned, including a little boy this summer who was pulled out into the River and died, after playing alone on its shores. He had been living with his grandparents, his father having run off and his mother away in another province working as a migrant laborer. Local authorities called his mother back to the Valley, telling her that her own mother was very ill. They feared that if they told her what had actually happened she wouldn’t even be able to withstand the journey, and they were probably right; upon hearing the news that her only child was dead she seemed to lose her mind, and was closely watched in case she should try to commit suicide.

Any little incident can turn into an emergency in a place like the Valley; even those who live on the Valley floor near the main road, and who are likely better off financially, are hours away from a hospital that could deal with any remotely serious issue. This is to say nothing of the poorer people who live many hours up into the mountains, which can only be accessed by footpath. A minor injury from a fall goes untreated and becomes a lifelong limp; a small cut from a tool or animal bite becomes infected and festers, turning deadly.

One day we were in the Valley, Barbara and I were riding down the main road in a little motorized vehicle when we saw a teenage girl we know pass us on her bike. We called out a greeting to her and she smiled, disappearing over a dip in the road. Sixty seconds later I spotted her again, this time lying unconscious by the side of the road. Her arms were bloodied and she couldn’t move – fortunately this was temporary and she was only in shock, probably having had a moderate concussion (wearing a helmet, thank god).

But what if she hadn’t been wearing a helmet? What if she had broken her back instead of cutting up her arms? The hospital in the Valley doesn’t know how to treat head injuries or perform involved, emergency surgery.

We managed to get her home and she is perfectly fine now – but you see how fortunes can change in an instant in the Valley.

I don’t know when I’ll next be able to go back with Barbara; the next few months are full of plans made or half-made, and then RP and I may be going back to the US. I’m trying to savor the experience of having been there as if it will never happen again. There is no classroom that offers the education that going to a place like the Valley can, but I’m excited to return to the classroom nonetheless; these experiences show you all of the gaps in your abilities, and teach you how insufficiently educated and unprepared you are to help people in situations of real hardship.

Here’s hoping that one of these nurse-midwifery programs will take me!

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Experience Overload Part 3: Miracles and Meltdowns

Miriam (Barbara’s foreign nurse friend) runs a free clinic out of her home one day a week, so Barbara and I were able to go a couple times when we were in the Valley. The clinic is a pure act of charity; Miriam’s resources to treat the many people who sit on her front porch each week are limited, and people are often seeking help for complex illnesses and injuries. Sometimes frustration runs high because people are clearly looking for a miracle cure – but in order to know why this is reasonable, you have to understand the mysterious circumstances under which healthcare is sometimes provided here.

As in many places in China, tuberculosis is endemic to the Valley. Cases here are often allowed to progress to a stage rarely seen elsewhere; permanent lung damage, disabilities from TB that has spread to and destroyed skeletal joints, and deaths are not uncommon. The government, however, does provide a certain amount of TB medication for free if you test positive, and Miriam is often able to arrange for a patient to receive this treatment. That can, indeed, seem miraculous – one day you have a cough and a fever, the next day you’re diagnosed with TB, and then this foreign lady makes sure that you get free medication and home visits so that you’re not going to die! From that perspective, why shouldn’t people turn up expecting to be cured of all manner of diseases?

Clinic days are long; the first patients have shown up by 8:30am, and we often weren’t finished until 5pm. At a desk job, that’s just a regular day – but when you’re seeing an endless stream of patients who often cannot be helped, you want to go home and go to bed without dinner at 6 o’clock.

What complicates matters is that many of the patients we saw had actually already been seen by a physician in one place or another – the Valley hospital or a village clinic – and simply did not like or did not understand the answers they received.

Some of these patients face deeply serious problems: one young mother brought her 2-month old baby girl to the clinic for intractable chest congestion. I have never seen a baby that looked like this before – she cried endlessly in a way that seemed to choke her every five minutes. She was clearly unable to breathe properly, and turned blue several times. At the Valley hospital the mother had been told that the baby did not have pneumonia, and they didn’t know what to do for her.

Fearing that perhaps the baby had cystic fibrosis, which would be tantamount to a quick death sentence in a place like the Valley, Barbara and Miriam advised the mother to take the baby immediately to the city hospital four hours away for further tests. Unfortunately, the young mother was living alone with the baby at home for the next few days, with her husband off working and in possession of all of the money. There was a discussion of scraping together enough money to lend her so that she could get to the city, but someone who spoke Azu and Mandarin would have to accompany her, since she did not speak Mandarin and the city hospital staff do not speak Azu. No such person could be found on such short notice.

Then there are other patients who have been told what to do to fix their health problems and are simply being stubborn about it. One amazingly wizened Azu woman presented herself on Miriam’s front porch complaining of eye troubles, eventually revealing that she had been diagnosed at the hospital with cataracts in both eyes. The woman was a serious character: at 75 years old, she stood perhaps two and half feet tall, a consequence of her dwarfism. She was dressed as if she had been plucked from her village and drafted into the Cultural Revolution-era military; she wore the traditional Azu women’s patterned skirt and embroidered vest, strung from neck to knees in beads and large shells, and had paired them with a camouflage green Mao hat and combat boots of the kind favored by the People’s Liberation Army.

Despite the fact that she had been correctly diagnosed, and that her problem was fixable with a very simple surgery that would be provided for free by a hospital right down the road, she refused to go, claiming that the doctors there would kill her. She quickly announced that she would only have her eyes operated on by a foreigner, and demanded to be sent to Kunming for said mythical foreigner to schedule her surgery.

We explained to her, in the nicest possible terms, that she was being a huge pain in the ass, and that if she wanted her sight back she should go get her free surgery down the road, where they were not going to kill her.

“You people aren’t helping me!” she companied, adding, “Plus my knees and hips are sore.”

Lady, you are a 75-year old with dwarfism who has done manual labor in the fields her whole life. My joints would hurt too.

*****

One of the strangest problems we’ve encountered at the clinic is infertility. Barbara and I were meant to be focusing on any OB/GYN patients, and apart from a few women with minor infections, they all seemed to be having trouble getting pregnant.

Infertility can be difficult to cure even if you have lots of money and all of the latest technology available to you. So what do you do when women show up at a free clinic halfway up a mountain side, with no lab technology, no samples of or understanding of any medications they’ve previously been given, and tell you that they can’t seem to get pregnant?

These are not 40-year old women who put off having children because they were busy with their careers or because they couldn’t find a suitable mate. Azu girls often start marrying by age 16, and everyone seems to be married by age 20. Marriage and childbearing and extremely culturally important, and therefore nearly universal. So again: what do you say to a 26-year old in seemingly good health, who had one still birth when she was 8 months pregnant seven years ago, who has been trying to get pregnant ever since, but who doesn’t quite understand the mechanics of how pregnancy actually happens?

Pesticide use on crops in the Valley is ubiquitous, and women often apply it with their bare hands – perhaps that’s the problem? Perhaps it’s their husbands who are infertile, having contracted sexually transmitted infections? Perhaps this incidence of infertility is no higher than normal in a population of this size, but because it’s so embarrassing for Azu women to discuss it they will only come to this free clinic, making it seem like we’re seeing unreasonably large numbers of infertile women? Who knows.

We drew lots of pictures, and explained in simple terms about the ovum traveling down the fallopian tube. We went over the possible causes of infertility, and even tried to explain how to monitor your temperature and other symptoms daily to determine whether or not ovulation is occurring. Even as I was explaining these things, I could see how hopeless the situation probably was for most of these women. They seemed to understand what we were saying, but were quiet; perhaps they knew how hopeless it was as well.

If we could help everyone who came to the clinic, the days would simply have been exhausting. But because we couldn’t help many of them, the days were not only physically tiring but full of anguish. Azu people are often happy to explain their health problems in front of other Azu, presumably because they are used to the very public nature of village life – so when one 36-year old woman approached me speaking so quietly that she was almost inaudible, I knew her problem must be very serious. Barbara and I took her into an inside room, where she presented us with a CT scan of her uterus. I don’t have any training in reading CT films, but even I could see that her uterus had some sort of mass in it, and what looked like only one fallopian tube. She said she had been trying to get pregnant for six years, and then dissolved into sobbing. She lifted her shirt to show the thick, dark scars lacing her abdomen from previous gynecological surgeries.

It was certainly not my place to give this woman a possibly faulty reading of her CT films, nor to pretend to understand how much pressure she must be receiving from her family to have a child at age 36. What was clear was that no one had ever sat with her for half an hour and allowed her to say how scared and upset she was about her infertility. We gave her advice as best we could, and she cried, “It’s hopeless, isn’t it? Isn’t it hopeless?”

It’s at times like these that I find myself wishing away the next few years, so that I can be done with my nurse-midwifery training and actually help a woman like this. Did we do anything to help any of these women in the Valley? Did we offer them hope, simply with our presence, that we then dashed by being unable to fix their problems?

How do you know when you’ve done a good enough job?

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Experience Overload Part 2: Hospital Regulars

We visited the hospital several times this week, checking up on the women who were of particular concern to Barbara. Their outcomes ran the gamut:

  • The woman with the seizures and infection had been doing better, but then her infection returned and she seemed to be retaining fluid at an undiminished rate. They had transferred her to a hospital in a city four hours away.
  • The woman who had had a cesarean after her labor stopped was much improved and, by our visit yesterday, had gone home with a healthy baby.
  • The woman with uterine cancer was gone from her bed, the sheets neatly folded. I assumed she had died, but was later told by a nurse that they had sent her home to die there – nothing more they could do for her at the hospital anyway, and they needed the bed.

For the record, I think this last outcome is probably a good thing. Just as a system in which hospital births are the norm for all women leads to lots of money being spent in achieving relatively poor outcomes, I think the same may be true of a system of hospitalized death.

In death, of course, unlike birth, the outcome is eventually the same for everyone. On the other hand, hospitalized birth and death have much in common: enormous potential for trauma; unnecessary and invasive procedures being performed, often without consent being given; massive quantities of money spent on these procedures; the transformation of a private, family affair into a sterile, clinical one. I’m still formulating my thoughts about this, and, in truth, have seen a dead body but have never actually seen someone die. Still, I think that establishing a system in which the beginning of life and the end of life generally occur out of the clutches of hospitals will be one in which more people have a good birth and a good death, instead of the undignified medical disasters so common now.

One of the nursing schools that I’m applying to has a minor in Palliative and End of Life Care; perhaps I’ll be their first midwifery student to take it up!

*****

One of the days we were at the hospital, Miriam (a foreign nurse friend of Barbara’s who has lived in the Valley for years) came by for a prenatal check up and ultrasound. The hospital staff were perfectly happy to lend Barbara a spare bed to perform the prenatal check up herself. Having seen Barbara do a few prenatal check ups, I knew that she would begin by asking a series of questions about Miriam’s general health and comfort, anything unusual during the pregnancy (Miriam has a number of children already, so she is very familiar with her pregnant body), and fetal movement. She then performs a Leopold maneuver, which is the process of manually palpating the woman’s belly to determine fetal position. Miriam said it would be fine if I wanted to palpate her belly as well – and judging from how exciting I thought this was, I can already tell what a geeky midwifery student I’m going to be.

Let me tell you: feeling the position of the fetus is not as easy as it looks. You think that if you palpate a pregnant woman’s belly you’ll be able to feel something concrete in there, but Miriam is around 7.5 months pregnant, so the fetus still has plenty of fluid around it. For the first few moments I couldn’t feel anything at all – just a dense orb of fluid, like a medicine ball. But then I felt a solid, unbroken line between her belly button and left flank – the fetal spine! – and followed it down to the head above the pubic bone. Her baby has been moving around a lot, but for now it’s in the perfect position for birth.

After using a Doppler fetal monitor to listen for the heartbeat (again, not as easy as it looks to get the fetal heart beat instead of the mother’s), we went with Miriam to another hospital building to get an ultrasound. I’ve only ever seen fetal ultrasounds done in China, so my experience is limited to what they do here, but so far I can’t tell a damn thing from looking at an ultrasound screen. It occurs to me that they may intentionally do them very quickly here, avoiding prolonged views of things you might recognize like the fetal torso, because ultrasound technicians are forbidden from revealing the baby’s sex. This is because one well-documented side effect of China’s “Family Planning Policy”, as it is known here, has been an exacerbation of the population’s lopsided male-female sex ratio, and a high prevalence of sex-selective abortion.

Supposedly, ultrasound technicians can lose their jobs if anyone finds out that they revealed the baby’s sex to the parents. However, I have also heard that bribing the technicians is common, and that technicians sometimes drop hints to eager parents – saying “Congratulations!” if it’s a boy but nothing if it’s a girl, for example. At the end of Miriam’s ultrasound, she and the technician exchanged a few words:

“It doesn’t matter to us what the sex is, since we’re definitely keeping the baby.”

“It may be a boy. We’re not allowed to give you any information because of the Family Planning Policy.”

Perhaps that was a hint, or perhaps they just say that to everyone.

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Experience Overload Part 1: Training Day

I don’t think I have it in me to put up a post every day, but I really ought to. Each day in the Valley reminds me of the summer that I took intensive Spanish (bear with me on this analogy) – one day was equivalent to a week, one week to a month, one month to a semester. If I let too many days pile up without ordering it all into neat paragraphs it seems impossible to process. We’re heading out of the Valley tomorrow at 5am after almost two weeks here, so it’s time for some wrap-up. So as not to tax your patience, I’ll put this up in pieces over the next few days…

Training Day

Barbara and I started off Monday by meeting with two Azu women to prepare our training for the next day. The training was to be for some 20 Azu village women, on a topic related to maternal and infant health. We are using the American College of Nurse Midwives’ Home-based Life Saving Skills manuals, which contain very basic, picture-based instructions on how to deal with life-threatening situations that can arise during pregnancy, birth and the postpartum period. They’ve been used all over the developing world, particularly in rural areas like the Valley, and are easily adapted because the pictures and text are so simple.

(Dear visiting Singaporean medical students who were bored and translated the text into Mandarin for fun: PLEASE STOP. I know you are all bursting at the seams with your newly acquired medical educations, but endlessly crossing out the ACNM’s text and replacing it with complex instructions that women who are barely Chinese-literate will be unable to follow is counterproductive. AHEM.)

The two women we met with decided that “Bleeding During Pregnancy” would be a good topic for the training, as this is something that they’ve encountered in their villages over and over. There ensued a flurry of translation into Azu (seeing Azu being typed out on a computer is supercool), cutting and pasting and photocopying, and BAM! Azu handouts on what to do in case of bleeding during pregnancy.

The training itself went very well, and that was not at all a given. Part of the issue in running such trainings is that any Azu woman will tell you that their main characteristic is haixiu – shyness. Azu culture is highly conservative and thick with taboos around issues of health and the body. It’s not at all certain that you’ll be able to get a bunch of women together and convince them to mime such things as urination over a plastic bucket and getting a friend or family member to keep track of how much blood they’re losing.

During the training there was much discussion of Azu women being haixiu and, given that, what people might actually be willing to do in case of bleeding. They agreed that urination would be ok because they can go off alone for that, but determined that they would keep track of their own bleeding, thankyouverymuch, unless they bled so much that they passed out – in which case someone else could take over.

Fair enough.

Haixiu aside, there are other, equally fundamental issues with running such a training – for one thing, it turns out that many Azu women have no idea what their internal anatomy looks like. If I said to you, “The egg travels through the fallopian tube to the uterus”, it’s likely that a little picture would pop into your head that originally came out of a biology textbook, or Our Bodies, Ourselves. These woman are largely extrapolating visuals from their experience slaughtering livestock, which can actually be useful if they’ve been butchering pigs, but not so much if it’s just been chickens. (I will leave it to you to Google appropriately.)

They are also hungry for information, which makes keeping the trainings on track a real challenge. When presented with a highly experienced and foreign-trained nurse-midwife like Barbara, every question they’ve ever wanted to ask comes forward. What do I do in case of a breech birth?…Why do they happen?…Why does the placenta sometimes not come out? It’s too much for a two-hour training – plus, we’ve got to come with better visual aids showing HUMAN anatomy next time.

One thing that doing such trainings teaches you is that just because people are shy, it doesn’t mean they have nothing to say. This is especially important to understand in the context of hospital care in the Valley, as whenever we’ve gone to the hospital, Azu women and their families are essentially silent in front of the Chinese staff.

We started off the training by having one woman tell the story of a girl in her village who bled seriously during the 4th month of her pregnancy, and miscarried. It was as if she had cracked opened the floodgates – out came the other women’s stories, slowly at first, then faster and faster until they were literally shouting each other down with their tales of pregnancies lost and saved, labors endless and precipitous, babies born alive and dead.

I started bleeding at three months and eventually the fetus came out, the size of a plum…I started bleeding at six months and the twins were born dead – they were girls, I could tell by then…My relative bled all the way from two to seven months, but her mother-in-law prayed every day and the baby was born healthy…A woman in my village had bleeding, so we killed a chicken, stir-fried its innards and made a soup – it saved the pregnancy…A woman I know started to bleed, but she carried to term and even had the strength to pinch and bite her husband during her labor shouting, “This is your fault! You did this to me!!”

I don’t think the staff at the hospital know (or care) what a fine line they are walking with the village women, what a slim margin of error they are being given. For women who are resentful that they have to go to the hospital at all, bad outcomes that happen there are not forgiven. One woman relayed the story of what sounded like a placental abruption and/or uterine rupture – either way, there was massive hemorrhaging. The woman survived, minus her uterus, but the baby died shortly after birth. I have no idea whether or not this was the fault of anything the hospital did, but the conclusion offered by the storyteller was clear: people in her village do not like the hospital any more.

I may be justifying my own ignorance, but with topics like these it strikes me that it may be a good thing that Barbara and I don’t speak Azu. She guides the training in English, I translate English-Mandarin, and another woman translates Mandarin-Azu – which means that these village women are free to say whatever they want, knowing that by the time it gets back to me and then to Barbara, the essential facts are getting through but the nuance is long gone.

In the end, they’re not really telling their secrets to us – and that is a good thing.

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Back to the Hospital, and Shabbes in the Valley

Home

I’ve parked myself with a can of beer in front of my room’s electric fan, vainly hoping that either will do something to cut through the humidity that has settled into the Valley over the past few days. Barbara and I just came back from dinner at the house of a foreign friend who lives near by; after dinner we sat with the lights off in the living room, eating a mountain of lychees to keep cool. I complimented her on her beautiful Peruvian wall tapestries, and was then distracted by the concept of a place as inconceivably distant from the Valley as Peru – it might as well be a fairy tale. I spent the rest of the evening staring out the window of her home, overlooking the skeleton of a small, ruined power station in which villagers now grow corn in tight rows.

Tomorrow morning we meet with two local women to prepare a training for village women on life-saving skills relating to pregnancy, the postpartum period, and newborn health. One of the women only speaks the local language – let’s call it Azu – and the other speaks Azu and Mandarin. I’ll translate from Mandarin to English for Barbara, and the whole thing will be a little round-robin of translation and take three times as long as it should, but as we say in Mandarin: mei banfa.

One of the ways I know that my Mandarin skills have improved since we moved to China is that the prospect of this kind of activity only makes me a little nervous, as opposed to paralyzingly nervous in a manner that requires closed eyes and deep breathing. Now I always do pretty well in these situations, if I do say so myself. It’s tomorrow afternoon’s plan, returning to the hospital, that’s got me a little worried.

Back at the Hospital

On Friday we stopped by to see the Matron, and when she wasn’t in that day we casually made rounds, mostly to check on the woman who had had the emergency cesarean and severe infection. She seemed to have improved somewhat from the day before, but as we stood by her bedside I looked at the woman lying in the bed next to her – and then I looked again.

I recognized the face peeking out from underneath heavy blankets, her eyes just showing beneath her “new mother’s” head scarf. When we had visited the day before, she had just arrived at the hospital in labor, with her water already broken. She didn’t seem to be in heavy labor yet, and when Barbara examined her she noted that the baby was posterior, its head wasn’t engaged in the pelvis, and there was very little amniotic fluid remaining. A posterior baby (“sunnyside up”) is often more painful to deliver, but will usually come out on its own with a little maneuvering. One whose head isn’t sufficiently engaged in the pelvis might not come out at all, necessitating a c-section.

There are ways to encourage the baby to move down, but the hospital doesn’t favor any of them. They don’t like the women to move around in general, and particularly not after the water has broken because they fear cord prolapse (that the cord will slip out before the baby, which can be fatal as it cuts off the baby’s oxygen supply). This is not a well-founded fear when there is very little amniotic fluid, so Barbara encouraged this woman to walk the hospital corridor and to stay well hydrated.

The whole thing was hopeless. Let me explain the issues.

The Problems of Hospital Birth for Azu Women

1) This woman had been hooked up to an IV of oxytocin, to make her contractions stronger – this IV bag hangs from a runner attached to the ceiling. It is not mobile. So if she wants to walk the halls (which the staff do not want her to do anyway), they have to unhook the IV from the ceiling and someone in her family has to trail around behind her, holding the bag over their head. This gets tiring, so they do it for 5 minutes, drop their arm, and then the staff tell her to get back in bed.

2) The woman was thirsty, but refused to drink water. She refused to drink not because she’s a fool, but because the maternity ward has no bathroom – so if she wants to use a bathroom she has to go at least downstairs to another ward, or to an outhouse outside the hospital, which is not all that appealing when you’re in labor. The maternity ward does encourage women to use bedpans, but they had run out of bedpans by the time this particular woman arrived. Even if they had given her one, the women don’t tend to use them because they are in open wards, with no curtains separating the beds, so they would have to use them in front of other women’s husbands and relatives. Not gonna happen if they can help it – so they drink as little as possible.

3) By the time this woman arrived, her water had already been broken for two days. She had waited so long to come in for numerous reasons, including: a) Azu women tend to minimize their pregnancies and labors as long as possible. There are taboos surrounding pregnancy and birth that mean such things are rarely spoken of; b) Many Azu women, including this one, live a tremendous distance from the two-street town center where the hospital is located – they don’t want to walk hours and hours down a mountain if they’re not sure whether or not they’re really in labor; and c) Azu women don’t really like the hospital. The care is free, and they’re even given a cash incentive to show up and give birth there, but they still often prefer to stay in their villages. The local government has made that a moot point by recently passing a law requiring them to come to the hospital, but many are still unhappy about it; they have a hard time communicating with the Chinese staff, many of whom don’t speak Azu at all. They feel looked down upon and condescended to by these more affluent “city folk”, who look different, speak differently, dress differently.

4) And then there are all of the larger reasons that any Azu woman here is disadvantaged giving birth; their diets tend to consist of only a few vitamin-poor staple foods at any given time (potatoes, cabbage, hominy). They generally receive no prenatal care, meaning that any problems tend to become emergencies, usually at the time of birth.

This particular woman finally received a cesarean several hours before we arrived at the hospital. In light of the other woman with the severe infection, seizures and emergency cesarean, the hospital staff had gotten too nervous to wait any longer – her labor had stopped, they told me.

And now here she was, under blankets, her baby in some distant part of the hospital. She was mumbling, delirious with pain, unable to open her eyes. I knelt down beside her and squeezed her hand – what else is there to do? – and tears began to stream from her eyes, forming a little reservoir where they reached her nose. She squeezed my hand back and began to sob and shake – I worried that I was making it worse.

I noticed a young man and an old couple nervously hovering against one wall of the room and asked if they were her family – yes, they said. Because the hospital has no chairs or stools for anyone to sit on, they didn’t know where to be. I managed to scrounge a stool from a closet so that her husband could sit next to her, so that at least she would know he was there. When I walked past the room later on, I saw him spooning soup into her mouth.

We’ll see if she’s doing any better tomorrow.

Shabbes in the Valley

I did not grow up an observant Jew, but I’ve been experimenting with a few things lately, trying them on to see how they fit. Last month I decided to start lighting candles on Friday nights, for Shabbes – I cover my head, I light the handles, I wave the flames toward me and cover my eyes, I say the prayers. When I’m done feeling like I’m playing dress up, the whole thing feels pretty good. The first prayer I should say, of course, is  to Adonai, Eloheinu, creator of the fruits of the internet – because seriously, I wouldn’t know how to do any of this stuff otherwise.

Shabbes is always supposed to be a welcome event in the week, but after Friday at the hospital it seemed particularly necessary to light the candles, to go through the steps, to create a break with what had happened before.

I hadn’t brought anything to the Valley with which to cover my head, so I went out and bought the first head scarf I could find, which is one traditionally worn by older Azu women. Barbara was suitably impressed, so she took this photo of me (in which I realize that the shirt-scarf combination is sort of a horrifying optical illusion of plaid – apologies).


On Saturday night, I lit an improvised Havdalah candle for the first time in my life, accompanied not by wine but by Coke Zero, which, unlike wine, is available all over the Valley. I liked Havdalah – maybe this coming week I’ll even spring for some fruit juice.

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