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…
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.
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.