First Words

I have heard the azan, the Muslim call to prayer, under the scorching sun and the early morning cover of darkness: at the edge of the baking savanna of Sumberwaru in East Java, green mangoes fat on bowed branches; at the lunar feet of the Anti-Atlas mountains outside Tafraoute in southern Morocco, the trembling voice of the muezzin competing with low thunder from the horizon and the tinny sound of Salif Keita from my travel speaker; watching the sun sink behind the Pidgeon Rocks of Beirut, Cyprus just off in the unknowable blue distance; over the PA system of an airless Dhaka shopping mall, the smells of new plastic sandals and sour milk mixing in the fluorescently lit stairwells; curling through stone windows into the Loge of the Empress in the Hagia Sophia, the great calligraphic panes bearing the name of Allah hanging over mosaics of the Virgin Mary like the tags of rival gangs in a subway underpass; and, most quietly, among the demolished neighborhoods of the Kashgar that once was, snow falling silently in the dusty streets, mustachioed men proffering glass goblets of pomegranate juice so thick and so tart. But I now most often hear the azan on the fifth floor of my modest brick hospital in New York City just after a child has come into the world, when he is still slick and grimacing on his mother’s chest wrapped loosely in a cotton blanket.

 

On an evening like any other, I emerge from a triage room, my palms wet with hand sanitizer. I recognize Rokeya from behind by her long, black pony tail shot through with strands of silver, now falling over the back of a wheelchair in which a nurse is conveying her to a labor room. The nurse’s leisurely pace is at odds with the fury of Rokeya’s pain so evident in her blanched knuckles and rigid arms. I have been on the floor for 12 hours and had stepped into triage for a quiet moment, steadying myself among the sterile specula and IV starter kits for a further 12 hours over night. Pressing my hand to the Purell dispenser on the way out the door is merely a tic I’m unable to break.

I feel a tiny righting of the course of my day at the sight of this woman, a relief after hours of triaging strangers. As a shift worker, I never know whose birth I’ll be attending when I wake up in the morning; when it happens that fate matches me with someone that I know and have cared for there is a locking together of puzzle pieces and a claim that I lay to her in birth: I know her, I say, I’ll take her.

By the time I enter her room, Rokeya is sitting upright on the bed wearing the standard-issue, blue-flecked hospital gown and a shocked expression, flanked by two silent women that I guess are her mother- and sister-in-law. This labor is nothing like her last, nineteen years earlier. Then she was twenty years old, in the blur of the first year of marriage, occupying a room on the first floor of her in-laws’ home on what was then the outskirts of Dhaka before a fleet of new concrete buildings swallowed the surrounding area whole. Then she was just a bride, still skinny, for whom life had proceeded largely as expected, who knew some material comfort as the daughter of a secretary to the Assistant Superintendent of Police of the Bangladesh Civil Service. Her marriage had been arranged without displeasure to Anwar, a round-faced youth hoping one day to pass the BCS examination himself and work alongside his father-in-law.

In those days, Rokeya was concerned with learning how to be a wife, having given up her study of medicine after her first year.  Whereas she had observed their preparation in her girlhood, she now took responsibility for her family’s iftar meals during the month of Ramadan, laying out dish upon dish of dried dates, ghugni and muri, jackfruit, jilapi. Rinsing blood from the cavity of a sinewy chicken’s body, she sometimes thought of the four cadavers weighed down with bricks in a secluded tank of beetroot-red formalin at the medical college; she had barely worked to hide her disgust as caustic fumes from the embalming fluid filled the laboratory and had waited as briefly as she thought respectable before accepting her mother’s suggestion of marriage instead of year two of the MBBS.

Piping thin batter into a pan of frying oil at dusk, Rokeya knew nothing of the recurrent miscarriages that were to come after the quick conception and birth of her daughter, or of the secret meetings with an elderly woman neighbor to discuss redressing whichever of Rokeya’s past misdeeds must have brought this misfortune on her family. She knew nothing of what it would mean to lose a husband after only four years of marriage, to have his name unacknowledged in a brief news report of the bus crash that would take his life, among a dozen others, on the proto-highway that cut through her neighborhood in an eruption of cracks like a dry riverbed.

She could not have foreseen her penetrating grief at the loss of that man she still only half-knew, her years of widowhood as a returnee to her parents’ house with her little girl, her eventual emigration to the United States to live with an aunt whose teeth were blackened with rot at their bases, or her remarriage at age thirty-seven to the bachelor proprietor of a 99-cent store on Church Avenue. She had never imagined our meeting in a windowless, antiseptic room of my prenatal clinic with barely enough space to fit the two of us, an exam table and a sink. Nineteen years earlier, she could not have known that the English she had so dutifully studied as a girl would be the language of our meetings, or that the first hands on her second-born’s head would be mine.

 

Before I entered midwifery, during my training as a nurse, I was taught never to sit on a woman’s bed during labor; it was deemed too intimate a posture between strangers. I often remember such admonitions from my favorite nursing instructor Moira, a warm and formidable Irish woman in her sixties, straight-backed and clad in pressed white shirts, intent on impressing upon us a respectability no longer guaranteed us by the profession alone. A nurse never sits! she chastened us students as we waited in the hall outside the simulation lab. Or, crooning over a medical mannequin: Now we’ll be administering digoxin, which we will never refer to as what? An anti-arrhythmic, yes, because it is properly called what? A cardiac glycoside, correct. That is what will set you apart… But Moira never taught us how to greet a laboring woman. I have learned by trial and error to stop asking a woman in pain how she is feeling, to avoid that temptation of the workaday greeting. I sit by her side, I call her by her name, I tell her how glad I am to see her, and I mean it. We are intimates, she and I, though we may be strangers.

On this evening, I lower myself onto the empty space beside Rokeya’s bent knees, the mattress crackling quietly beneath my weight, the air full of her moaning. She does not address me. “I am in pain–”  she says to the room in general, “– too much pain — not like before — not like last time –”

Her female relatives sit gravely at either side of her bed, their sure palms resting on her arms, as still as geckos high on the wall. These women are not the typical family members who stare alternately at the electronic fetal monitors and at their smart phones; they know something about labor and, I sense, about pain more broadly: that it requires the full attention of those in attendance, that it demands a steadiness that betrays no doubt, no impatience, and no fatigue. When everyone else in the room is poorly equipped for birth, frozen in a corner or skittishly scanning their social media, I know that the night will be long and that I will collapse into a narcotically deep sleep long after daybreak. But for Rokeya I provide only the most basic of assurances: that I will do everything in my power to ensure that she and her baby will live, leaving the rest to her own efforts and the comforts of those who truly know her.

Hers is the progression of the unanesthetized body: sweat forms at her hairline and then at her upper lip; a contraction comes and she presses her fingertips into the muscles above her pubic bone; she sticks her chin out before vomiting into a pink, plastic basin that the nurse has placed by her side; she says that she just cannot and we tell her that she already is. She pushes just six times to move the child’s head out of her body — why do I gingerly dab a whorl of his wet hair just then? One more endless push and his body emerges in a rush of fluid into my hands. I hold him suspended for only a moment before placing him on Rokeya’s chest, the pulsating, dusky coil of his umbilical cord still connecting him to the inside of her uterus. Her cries turn to weeping and she clutches this wet, squalling creature, his eyes black and open, his ten fingers splayed in taught fans like the petioles of two palm branches.

Her mother- and sister-in-law wipe drops of sweat from their cheeks and adjust the dupattas they have let fall from their heads during the work of supporting her. I take in their faces now for the first time and notice a split-second of bewilderment come over the mother-in-law. Her eyes scan the room, seeking some object unknown to me: I am not it, neither is the nurse who is occupied with injecting oxytocin into Rokeya’s thigh to prevent bleeding.

Allah, she mumbles, seemingly in spite of herself. Allah — and I remember what she is looking for: a man to whisper the azan to the baby, the first words it will hear in this world, on this side of the birth divide. Finding no man, avoiding her daughter’s gaze, she leans over her grandchild’s head:

Allahu akbar, she says in a small voice into the newborn’s right ear, and then again, more steadily, Allahu akbar. She slowly turns the baby’s head to reveal his left ear — Allahu akbar — as I see the sister-in-law dialing a number on her phone. She has called Rokeya’s husband, still detained at the 99-cent store on Church Avenue. It seems he has been expecting this call and he wastes no time by greeting the callers; the phone is positioned over the baby’s right ear and from the pinhole speaker comes the improbable, quivering voice of this man who thought he might never be a father. The room comes to a hush, the regular chatter about the baby’s activities and, worse, the nurses’ business with women in the adjacent labor rooms, silenced. His thin intonations fill the labor room:

Hayya ‘alas-salah — Hurry to prayer
Hayya ‘alal-falah  — Hurry to success

We hold onto this woman, a new mother again after so long, I at her feet, her mother- and sister-in-law at either arm. The newborn is placid, pacified, evincing life only through his pink skin, intensely concerned brow, and the occasional involuntary twitch of his limbs: his first alpha sleep on earth. The mother-in-law turns the baby’s head once more for the recitation of the iqama, which the father begins remotely and without hesitation:

Qad qama tis-salah — Prayer has begun
Allahu akbar!

I encourage the afterbirth with gentle traction on the umbilical cord, twisting the purple body of the placenta like a cheesecloth as it comes into view, gathering its membranes together to prevent their tearing, catching it all in a metal kidney basin between Rokeya’s thighs. Her bleeding stops, she needs no stitches. I look up and observe her as she murmurs in Bangla to her son, barely ten minutes old and already awash in words and words. Whole volumes are written recording our last words, our dying words, but what of these first words from the birth bed? Would there exist other such volumes if only Great Men had given birth? Is it not enough that I once knew an old midwife whose husband had died in Vietnam and who whispered into the ear of each new baby: Be well and may you never know war!

I am reminded of the words of 16th century poet Kabir, so withering in his criticism of the faddish distractions of religious practice and of the muezzin’s ostentatious cries heavenward to grab God’s attention:

Surely the Holy One is not deaf, he writes.
He hears the delicate anklets that ring on the feet of an insect as it walks.

Had he himself witnessed that thing most unassumingly holy, that sanctity that needs no naming and no exegesis? Had he himself heard the tiny, tin bell of birth?

A Night in Three Acts

This particular summer night on the labor floor unfolded in three acts over 12 hours, beginning just before eight o’clock in the evening. Caffeinated and in clean scrubs, I entered the floor through a set of massive metal doors, doors that require electronic hospital ID to open, doors that lock down with a blaring of alarms numerous times each day when a newborn becomes accidentally separated from the security tags attached to its wrists and ankles as if it were merchandise at the mall. I strode through the doors and glanced reflexively up at the well-worn white board in front of the nurses’ station where the labor rooms and their occupants are listed in the semi-encrypted medical shorthand meant to offer a patina of anonymity: J.L., 24, G1P0, 39+4, 3450g, 6:35A 5/90/-1 AROM cl 5:05A, neg, low, consulted. Y.C, 16, G2 P1, 34+3, 3100g, 7:45A 7/80/0 SROM lite mec 2:00A, pos, med, epi, PCN G.

But today the board was empty, the floor quiet, rooms waiting for grimacing women and their listless families. The empty board engenders in me both relief and anxiety: there is a moment available for a deep breath before the day begins, but there is no foothold in the day, no woman with whom to begin, only the promise of labor —  or no labor.

We — the midwives, nurses and obstetricians — use the time to complete rounds upstairs on the postpartum floor (Room 17 is doing well and wants to go home today…Room 8 was found sitting on the floor while her boyfriend was asleep in the bed…Room 13 doesn’t want to feed or touch the baby, but we’re not sure — maybe it’s a cultural thing?…) and I scribble notes to remind me of the tasks to be completed with these women, these new mothers, between 10pm and 6am when I will find them bleary-eyed in the dim light, clutching their infants, the hospital televisions throwing a silent, alien glow around the room.

I return to the labor floor and position myself at a computer from which I can see those hulking, metal doors in the periphery, reviewing the results of the lab work I have ordered for women in the clinic. While waiting for the sudden work of a woman in labor, I make phone calls as gently as possible (Yes, you have chlamydia, which is an infection you get by having sex without a condom with someone who also has chlamydia…The results of the fetal echo, the scan of the baby’s heart, show that everything is normal right now…) and continue developing that specific legal skill of documenting in a medical record: writing sparely, including only necessary statements of fact, making note of other clinicians’ support of my decisions, a style of writing born of professional fear and the trauma of the courtroom.

In between these points of investigation and documentation I close my eyes and allow the blackness there to create space in my mind as I learn how to deal with such utter uncertainty, as I wonder how anyone accustoms herself to the truth about this moment — which is, of course, the truth about all moments: that anything could happen.

Act I began just then: a slow opening of the doors and an uncommon sight: a pregnant woman, her face drawn not in pain but in resignation, accompanied by a starched, uniformed nurse, her eyes round and worn from years of already knowing what will come next. Puzzled by a pregnant woman with a nurse personally assigned to her, I parsed the story one leaden detail at a time: the nurse’s sole responsibility to this woman was to visit her at home to make sure that the baby still had a heartbeat. At today’s visit, 31 weeks into the pregnancy, it had not — an eventuality that the woman herself had both dreaded and, seemingly, anticipated. While this was the longest her body had been able to sustain a pregnancy, it was the third pregnancy in a row that had ended too soon, the third time she would enter a hospital pregnant and leave with empty arms. We hoped to reassure her, to find the galloping heartbeat hidden in some unlikely corner of the abdomen and to project its waveforms from the electronic bedside monitor onto the flatscreen in the hall, but there was no heartbeat to find. The task now was to induce her labor with medications, having moved her to the most remote of the labor rooms on the western side of the floor, from which we hoped she would not hear the first cries of other women’s babies being born.

It was determined that, as a brand new midwife, perhaps this should not be my responsibility; I did not object. I stirred a cup of weak coffee as her wheelchair was pushed past my desk and did a half-hearted literature review of the efficacy of inducing labor with one medication versus another. The coffee went down in hard swallows; I did not settle my imagination on the experience of losing, repeatedly, the pregnancies one so badly wants.

Some time later, the sun long since below the horizon and the moon on the rise, Act II began with a rush of voices and the high, pinched whimpering of a woman trying not to push her baby out in the hallway. She carried herself gingerly through the metal doors, eyes cast up to the ceiling, her long form clad in a simple cotton gown of midnight blue that brushed the floor. A shorter, older woman, head wrapped in a black hijab, supported her at the arm; she seemed familiar with the labor floor and knew into exactly which triage room she should steer the obviously laboring woman. The triage nurse hurried after them, surely planning to go through the standard routine of gathering a brief health history, taking the woman’s vital signs, and putting her on the electronic fetal monitor. But instead —

BABY IN TRIAGE!

At the controlled panic in the triage nurse’s voice we two midwives bounded into the room, followed by two further nurses, in time to see the laboring woman perched precariously on the narrow exam table, her cotton gown thrown up about her waist, her sinewy legs jutting straight out, the beginnings of a baby’s head emerging from between them. Our beseeching attempts to have her stop pushing were of no use;  even if she had not spoken a minority West African language unknown to our phone translation service, when a woman is pushing there is little you can do to stop her. Amid the sudden flurry of activity —  grabbing gloves and holding one tense hand at the woman’s perineum in an attempt to prevent a laceration, grabbing clamps and suction bulbs from the supply closet, pulling baby blankets from drawers — there was one slow-motion moment in which I stared at the emerging head and thought: Something is different here. In those endless few seconds I surveyed the woman’s genital anatomy and realized that something — or some things — were missing, although I could not tell exactly what. Was it the inner labia that were missing? Perhaps also part of the clitoris?

The baby emerged then, a slightly scrawny girl child, rosy and crying, eyes giant and alert. I tended to her as she lay on her mother’s chest while my fellow midwife ensured that the placenta was born and that the bleeding was controlled. Satisfied that the baby was well, her lips in an exploratory, open pucker next to her mother’s left breast, I stepped in next to the other midwife and watched as she inspected the genitalia for bleeding that would require sutures. The tissue beneath both remaining outer labia had separated slightly in descending, symmetrical lacerations but was not bleeding. The midwife decided that suturing would cause more harm than good, that the lacerations would heal on their own. I silently nodded my assent. When we stepped from the triage room to document the events of the birth she remarked that the lacerations might even allow the labial tissue to expand. “What used to be labial tissue,” I said dryly. “Oh, there’s plenty of tissue there,” she replied.

A low buzzing in my brain, static and numb. I completed the baby’s birth certificate in black ink; I did not settle my imagination on the ritual excising of women’s flesh, or on exactly how much of my own would have to be removed for it still to be considered plenty of tissue.

The clock ticked past two o’clock, and Act III began with the arrival of a stately, freshly showered, laboring woman accompanied by her boyfriend and mother. Pregnant with her third child, she had labored at home since yesterday afternoon and now leaned forward onto the clerk’s desk during the frequent contractions, swaying her hips and dropping her head while exhaling noisily. When I examined her in a triage room I found that her cervix was already six centimeters dilated. Her pregnancy had been uncomplicated, she said breathlessly and, as I searched through her medical record for evidence of anything concerning, I found no lab values out of range, no unusual social concerns, no abnormal ultrasounds or genetic screenings. Normal, then — low risk. I checked again to be sure.

The nurses moved her to a labor room and I settled onto a low stool at her bedside while they set up “the table” — a spread of all the items we had scrambled to assemble for the woman who had given birth in triage earlier on. A woman who has given birth before can move with great speed from six centimeters to fully dilated and pushing; having no one else to tend to, I stayed with her. She retreated to some remote, inner world during the contractions, her body still, her face tensed in concentration and pain, her boyfriend and mother hovering nearby, occasionally looking over to me for direction. I nodded to the boyfriend that he should sit by her other side, and together we proffered our hands and arms for her strong grip. I offered the only words one can offer in the face of another’s pain: words of soft encouragement and compassion; patient words.

The room was still. The minutes passed in unknown number.

Just then her eyes flew open and she fixed her eyes on me in desperation: “I have to push! I have to push!

“Wonderful,” I said. “I think you should have this baby then.” I rose from the bedside and removed the ID from around my neck and my watch from around my wrist — objects that might get in the way — setting them on the windowsill. I uncovered the table of birth supplies and removed a plastic sheet from among its many items. I turned back to the woman and her two family members and found them all looking at me expectantly, as though somehow I were now going to remove the baby from her body. I wedged the plastic sheet beneath her hips. I told her that she was just fine and that she should push the baby out whenever she felt like it.

“You have kids, doctor?” the boyfriend asked. I replied that I did not. “Well, you’re going to be a good mother,” he said, a compliment that is, to me, unlike other compliments.

And then she began to push, her muscled body shuddering with the effort, each push growing from a low growl to a short scream: the sound of power on the release.

Perhaps two minutes later, looking out at a starless, seamless, black sky, she gave birth to her baby: a boy, fat and healthy. The woman was well, and as I watched her meet her son and bring him close to her face, kissing him and breathing him in, I allowed myself that most modest of pleasures: to release the grip that I hold on my heart; to be overcome by relief at all that is so normal, and so good.

The Way the Day Begins

I sleep, unwisely, right next to a large set of windows. On these long summer days, I’m woken in the morning by the diffuse, white sunlight before I need to be up for work — a terrible curse for a sleep-deprived midwife. I could move my bed, of course, but I just can’t give up staring at the stars at night. As a child I had a skylight right above my bed and I seem always to be trying to get back there.

Today I wake up slowly after a 5am rain to the sound of cars passing lazily through the puddles down below, convinced in my half-sleep that it’s the sound of waves breaking on the beach. I roll over to the open window and lay my head on the sill. The dregs of last night’s activities on my tiny street are still playing themselves out: a single firework from an unknown location explodes in a sharp crack, upsetting a yappy little white dog occupying a window frame across the way. A pair of teenagers sing to each other in a tipsy drawl. A woman wanders slowly up the sidewalk repeating, sing-song, Somebody please heeeeeelp me, somebody please…

Scenes of yesterday’s prenatal clinic replay drowsily in my head: the muffled feeling of babies’ elbows and feet rearranging themselves in utero under my probing hands. The woman with an infection so severe I can diagnose it on smell alone from five feet away. The minute I take to compose myself before telling a woman that her fetus has Down Syndrome. The Syrian woman whose previous prenatal records I try to obtain before she gently stops me: The hospital over there burned down, miss. Everything burned down.

I resign myself to being awake and push myself up against my pillows. I give a glace to the other side of the bed, to the place that used to be occupied by my husband, back when I was a wife. I pull on the worn jeans and white t-shirt that will be wet through with sweat by the time I finish my hour-long walk to the hospital in the early morning humidity. I am ready to leave my apartment in minutes.

I love my walk to work; I am treasuring it particularly now that I will soon be moving to a neighborhood far from the hospital where I was lucky enough to find a job a few months ago, my first real midwife job. My mornings will consist of a long subway journey from one end of New York City to another, overground and underground, and I’ll miss the strange landscape that I now wend my way through each day, making note of the objects strewn across the sidewalks like props leftover after the actors have taken their bows:

A stiffened brown sparrow that the flies have taken to; an open bag of half-eaten green grapes; a small pile of watermelon rinds right on the concrete corner. A single stiletto in matte gold, upright on its needle heel; a boxy TV overturned on its face. A calico deli cat, ears flattened in displeasure at my approaching step. Tiny ziploc baggies that last night held heroin or cocaine.

The faintest whisper of a particular sickly odor reaches my nostrils and I hold my breath before it can overwhelm; it is the smell of dead animals that leaks out from under the rolling metal shutters of a storefront market selling poultry, rabbits and guinea pigs.

On my right I pass a caged basketball court containing a teenage boy practicing his dribbling before-hours, the ball tied up tightly in plastic shopping bags to keep it looking brand new. The train clackety-clacks relentlessly overhead, mostly empty of passengers at this hour, as I turn the corner towards my hospital. I arrive at the front doors breathing heavily, full of energy, as the hot sun punches through the clouds overhead.