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 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?

The Useful and the Beautiful in the House That I Have Built

The midwife comes home to a many-roomed house; dim lights illuminate the windows even when she is away at her work. After a day that began before sunrise, the door to the house comes open easily. She turns no key; there is no lock. As she enters, the scent of the house comes over her: cool, humid, gently salty, as if just inland.

She reaches her hand out in the barely lit entryway and leans her weight against a section of wall painted in a woman’s hot exhalations, the exhalations that came when she insisted that all of her strength was gone. She feels for the switch of a lamp in the corner and the light appears as the pale yellow of a woman’s closed eyelids, her head thrown back against the pillow, resting atop the mountain of her success.

Underfoot, the floor is an intricate network of wooden inlay: a late gush of blood interlocking with an urgent grip on the midwife’s arm that leaves a bruise the next day. A sharp creak as she ascends the stairs; one finger held silently at a woman’s lips — Please, he can never know. Her house is this way: drawing the curtains for the night, a woman’s long black hair held away from her neck, damp with sweat. Sinking heavily into the bed, pulling starched sheets up over her legs, the delicate weight of a newborn laid in her arms — We did this together. Somewhere in the house is always the first birth: a back-issue magazine consigned to a high shelf or a deck of stiff playing cards in the side table drawer.

She can’t remember the day the house was finished — wasn’t it built by some other midwife? Some years ago she spent a single night in one of its small bedrooms looking out onto the street, the sidewalk dark and damp with late autumn rain. Over time she spent so many nights in the house that it simply made sense to stay; one day she finds that she has carved her initials into the soft wooden banister. She recalls no single moment in which this became her home, no date on the calendar to distinguish the before from the after.

But if you have time, let me tell you a story of before and after.

*****

A nurse approaches me on the labor floor, tapping a ballpoint pen to the clipboard she holds tightly in front of her. “Twenty-one years old, baby number one, 32 weeks pregnant, not feeling the baby move,” she reports. She rattles off the woman’s vital signs and most recent lab results. “She’s not ours,” the nurse sniffs — that is, she does not come to us for prenatal care. “She’s in triage room 20 whenever you’re ready for her.”

Rising from my desk I cross the floor and take a moment to read the electronic fetal monitor displaying the pattern of the baby’s heart. I watch this jittery yellow line proceed across the screen, its occasional rises and returns painting a reassuring digital picture. Below that, a line reflecting the electrical activity of the uterus: flat, quiet, no contractions at all, just as I would hope for in a woman only eight months pregnant. Without laying eyes on the woman I know that her baby is likely in fine condition.

I casually consider what I will tell her; I am also thinking of the previous two women who have appeared in triage with the same concern. I am also half-considering: a training on breastfeeding that I need to complete; the birth I attended yesterday and what I could have done to prevent the hemorrhage; the anthropological text on birth practices in south India that I haven’t yet finished; a letter I’d like to write.

Entering room 20 I find a young woman seated on the exam table; she is outfitted in clean, dark leggings, a tidy yellow sweater and glasses framed in navy plastic. Her hair is smoothed into a tight, shellacked bun. The mildly chemical scents of dandelion shampoo and laundry detergent perfume the air. I know that I will find her skin softly clammy with cocoa butter; she is presenting her body for examination.

I introduce myself and ask her what has brought her to the hospital this evening. She stares at the pastel walls of the triage room. “I don’t feel the baby moving so much,” she says. She is hoarse. “Also I think I have the flu.” I help her lie back and see her wince when her shoulders reach the worn, brown plastic of the exam table. I ask her if she is in pain. “Oh yeah,” she says flatly. “But it’s nothing new. I hurt all the time.”

As she pulls up her sweater and I place my hands on her abdomen I immediately feel the unmistakable form of a fetus changing its position, its intentions unknowable as it flexes and extends, as it draws fluid into its lungs and then expels it, an imitation of breathing. I gingerly take the woman’s hand and place it atop the mound of her belly. “Do you feel this?” I try to look her in the eye but she has shifted her gaze to the ceiling. “This is your baby moving.”

She is quiet, and I am quiet, and the grainy, electronic representation of the fetal heart is the only sound in the room, rising and returning. A thought crosses my mind of a woman’s complex perineal laceration that took me an hour and a half to repair; I wonder if she is healing. 

”Oh. Yeah well I guess I do feel him now.”

I take in the picture of this woman on the table: no sore throat, no vomiting, no diarrhea, no chills or malaise. The nurse has already told me her temperature but I place my hand on her forehead — no fever. She closes her eyes under the weight of my palm and tears begin to drop heavily from the beneath her glasses; I pull a cheap cardboard box of tissues from a drawer beside the table and touch one of the thin, white squares to her cheekbone. She takes it from my hand and covers her eyes.

I take the bulky monitors off her abdomen and wipe ultrasound gel from her skin. “Your baby is just fine,” I tell her, “and I don’t think you have the flu.” The corners of her mouth tense; her eyes are giant with tears as she stares at the fluorescent light fixtures.

“But you are not fine,” I add.

And the words surface in my head: And I am not fine. They are new to me and are quickly submerged beneath the memory of a man who assaulted his wife in triage last month, trying to pull out her IV before we called the police.

She shifts to her right and pushes herself up awkwardly to sitting. Nudging her glasses up her wet nose, she looks at me. “Doctors always say the baby is fine. I come in and they check the baby, they say the baby’s fine and they send me away. But I think I’m dying.”

And I am not fine — the thought turns over in my head.

The details tumble out: bulging discs in her spine that make it hard to walk or sit, prescription pain medications that she has been warned against taking while pregnant, chiropractors and physical therapists refusing to see her until after the baby is born. Severe depression for which her physician will no longer prescribe her medication because “it might hurt the baby.” Counselors that are angry at her for missing appointments; she doesn’t want to get out of bed anymore. No one at home to help her prepare for this baby that she doesn’t want, no one to put a hand on her lower back. Pain in her mind and pain in her body, each intensifying the other until she has come to this moment in which it seems that she is dying or would like to be. Then she asks if, when the time comes, we could please numb her and do a c-section so that she won’t have to feel anything.

I exhale heavily. Another black man was shot by the cops for no reason last week; today’s news is full of images of the protesters. And then there is this woman in front of me.

I tell her that see her terrible pain and that I will not send her out of the hospital without making a plan for her to feel better; I tell her that she is a human being not an incubator and that she deserves to feel well. I ask her if she has a plan to hurt herself or someone else and she says that she does not. I ask if she would agree to speak with our social worker and she says that she would. I ask if she would like me to take care of her for the rest of her pregnancy — she says yes, and the yes feels like a bright green tendril in the dirt.

She and I sit over a clean sheet of paper and make lists: the medications it is safe for her to take; the ways to soothe her back pain until our medicine clinic can evaluate her; names of friends and relatives that she can call on for help; problems she would like to talk about with a counselor. We write this all down because it is something for her to hold on the way home, to keep in her coat pocket, and because in writing, unlike in thinking, you must eventually come to a stop. I make her an appointment to see me in the prenatal clinic the next day at eleven o’clock and, because no one knows what a midwife is, she says: “You’re the first doctor who ever listened to me.”

I am aware of a growing pain in my chest, a crackling like circuitry on the fritz.

As I watch her leave the labor floor I imagine: the next three women who will appear in triage with the same concerns; the next birth during which there will be a hemorrhage; the long run I will take when I get home. I think of the woman whose labor I will be inducing later this evening, wonder when the first labor was successfully induced with modern medications, and think how interesting it would be to read a social history of the induction of labor. My boss’s comment to me during my recent job performance review appears in mind: “Even during an emergency we look at your face and can’t tell that there’s anything wrong — that’s a good thing.” Because I am not fine. Some time later, my shift comes to an end.

 

The next morning in the prenatal clinic my breath feels uncomfortably humid. There is a bitter taste on the back of my tongue; my body is electric and ungrounded. It is 10:50, it is 11:00, it is 11:10. I have no sooner realized that the woman from triage is never coming to her appointment than another woman’s chart appears on my desk for review. I stare at it blankly.

There is a knock at my clinic room door and, before I can answer, the midwife next door has stuck her head in the room. Katherine is a senior midwife and a comfortable presence: she speaks with calm and deliberateness; she places her hands surely. She outfits herself in soft knits and delicate beads and sits with the stillness of a cat. I see her mouth begin to form its typical inquiry into my day, “You doing ok?” — an offer of her experienced perspective, should I need it — but she sees something in me and stops, her face arranging itself into concern. Slipping into the room and seating herself next to my desk, we look at each other the way animals do, without fear or social grace. Her eyes are serious and unblinking as I recount the story of the woman from triage room 20, of my hours spent with her, of her hopelessness, of her failure to appear today as if she has broken a promise to me.

“What’s her name?” Katherine asks me.

“Her name?”

I search my memory and find only the crackling of circuitry on the fritz. Some low panic comes over me — what is her name?

I have been told that I have a memory like a steel trap: so sharp that it makes those close to me nervous. I will remember: the unstable living conditions of a woman I met once three months ago; the exact wording of an argument I had last summer; the exchange of vitamins and minerals in the kidneys as explained during a lecture in graduate school three years ago. But for the first time in months I find nothing in my mind at all — no thoughts of tasks to be completed, no blood tests or chest x-rays to be ordered, no clinical questions to which I’ve been meaning to look up the answers, no reminders of books to be added to my personal reading list.

After some pause, I say all that I can manage to Katherine: “I can’t remember.”

She trusted me, she told me that I had helped her, and today I can’t even remember her name; we are strangers to each other, after all. I cover my face with my hands and find that my cheeks are damp with single tears.

With no preamble, Katherine tells me that I have burnout, and asks me how long I’ve been at this job. I protest that it’s been less than a year, so burnout is impossible.

“And how long ago did you attend your first birth?” I don’t answer.

Yes, that first birth: five years and two months ago, as a doula in a public hospital in China’s Yunnan province. That I will always remember — the woman, her birth, her son, his name: Gabriel. Born into my bare hands because there was no one else, because the instinct is to reach out hands to catch a baby falling into the world. Dabbing my cheeks dry with a paper towel, the room smells faintly of the thin Himalayan air at 11,000 feet.

“I remember this moment when I was a new midwife,” Katherine says plainly, “before I understood about the trauma.” She outlines a plan for how I am going to complete this day and for what I will do when this day is over. I want to be listening because the plan sounds like a good one — something about rest and self-care — but I can’t, because I don’t believe her. What trauma? That total exhaustion, that dim view of humanity, that pop psychology explanation for being not strong enough or compassionate enough — that doesn’t sound like me at all. I tell her as much and she looks at me with an expression that goes some distance beyond pity.

And so, because the will to excuse our own dysfunction is so strong, that is not the moment between the before and after of this story. It is only some days later, after yet another night shift with its bleary sleepless hours punctuated by the adrenaline of birth, and after a long drive out of New York City, up the east coast to New England and back again — the miles passing beneath my feet opening some meditative corner of my heart — that it finally comes. I find myself at home slowly returning to their rightful places all of the untidy objects of my apartment: the mail that has accumulated on the glass coffee table, the shoes lying on their sides in the hall, the empty teacup on the window sill. My whole body hurts. I roll a mat out on the living room floor but there is no way to stretch out the pain; I give up and begin to fold my clothes instead.

As I sit turning back shirt sleeves I feel slow a heat come over me, rising up my spine, up my neck and behind my ears, finally settling in my forehead. For a moment I think I’m coming down with something; I actually get out a thermometer but there is no fever. I go to the mirror by my bed and, leaning towards it, hope to see the face of someone familiar to me: one who comforts a woman with a warm and steady hand, one who brings her a measure of peace. Instead, I see for the first time what Katherine saw: a tension in my face that I barely recognize; I am not fine. Although it should have been clear, although it is everywhere in my writing, I only now take in the full picture myself in this moment and on my face I see: the terrible violence in women’s lives, their stab wounds and HIV infections; their stillbirths on the sidewalk, their babies brought onto the labor floor in plastic buckets; their babies born having seizures; their babies born addicted to drugs; their infections and lacerations and hemorrhages that I have worried are my fault. I look in the mirror and see these things for what they are. I call them trauma and it sounds, suddenly, correct.

I close my eyes and feel my mind go silent, as if the plug has been abruptly pulled on that crackling circuitry, all of the painful energy draining from me in an instant. My body is cool and quiet, a long fever finally breaking.

*****

I awake in a darkness like the pupil of an eye. Throwing off my heavy blankets and feeling my way out of the bedroom, I enter the kitchen and put my hand into an open drawer, withdrawing a box of matches. I strike one and it springs into flame. Moving to the kitchen window I touch the match to the wick of a short, white taper candle waiting upright on the sill, and then to another. Long shadows appear behind the objects of my kitchen: a purple glass vase in the shape of a woman’s gratitude; she says I took away her suffering. A thin trail of sulphurous smoke from the extinguished match curls through the air: the first time I surreptitiously leaned in to inhale the finely scented skin of a newborn’s head, feeling like a pickpocket. I move from room to room in this way, lighting candles, lighting lamps.

What is this house that I have built? On what date did I see these rooms for the first time, and when did I come to dwell in them? That first day when they said Get the midwife! and they meant me? — no, years before then. My first birth of midwifery school? — no, even before then I had laid the foundations. The first time I was taken in to a woman’s confidence? — perhaps then, although that is a memory long since faded.

There is certainly this: five years ago, when I said that I would one day do this work, women began to tell me the stories of their own pregnancies and losses. So eager were they to unburden themselves that I found I needed only to hold out my hands and women would give me their stories of pain and triumph like bricks and bolts of cotton, like lengths of pine and knotted rugs. I never thought to choose among these stories or to put them aside; I collected them all in case I disrespected a woman by forgetting her, in case I might need them again, and because it was it was possible to keep them all when there were only a handful of such women, before they became fifty, then a hundred, then five hundred. When my arms could no hold no more, I stacked the bricks into walls and laid the pine into floors; I built a house from the intimacies of women, sewing the cotton into pillows and rolling out the rugs beneath my feet.

I was reminded recently of William Morris’s admonition that we should have nothing in our houses that we do not know to be useful or believe to be beautiful. Standing in the light of incandescent bulbs, taking in the walls of what has become my home, its objects illuminated by a dozen tiny fires, I see instead of such curation the horror vacui that I have created over the course of years: books stacked from floor to ceiling, all of the infections I have cured; a hundred landscape paintings, women’s internal places of retreat during the pain of labor. Paper bags of bric-a-brac wait in the hall: recollections of hard night shifts destined for delivery to the doorsteps of unsuspecting friends and lovers. My cheeks burning in this recognition, I am nonetheless grateful that in the diagnosis lies the cure. Settled at my broad mango wood table during quiet evenings and the long hours of a post-call afternoon, I am now turning these objects over in my hands: does it serve me to remember those mistakes that caused a new mother’s fever? Is my life more exquisite for the addition of a new father’s prayerful exclamations at the birth of his son?

I have a fear of the cold and dark months, associating them with the theft of my freedom, with being forced indoors away from the freezing rain. And so I am amazed to find, for the first time in years, that I feel no dread at the close of these short December days but feel instead a peace like the quiet whistling of a kettle on the stove.

In the dark of this winter, at this turn of the year, I am giving away these possessions.

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.

One Year Later: I Made It, and I Didn’t

This morning I awoke at 7am to a still-dark sky holding a perfect half moon. I had been awakened by gently insistent church bells from the village of Gissey sur Ouche, 200 km west of the French border with Switzerland, where the boat that I am aboard with my family had tied up for the night. The canal that we are traveling, the Canal de Bourgogne, was constructed some 200 years ago to connect the river Yonne at Laroche-Migennes with the river Saône 242km away at Saint Jean-de-Losne. Once an important commercial artery, the fact that this distance can now be accomplished by car in a day has rendered the canal the province of pleasure-seekers and those otherwise committed to inefficiency in their travel, which I certainly am.


My sister recently pointed out to me that it has been a year since my last post here, which is as good an excuse as any to begin writing again. During the years that I lived in China, so full of travel, love, and outward explorations of the world, I would often think, “Now this is what it means to be living.” In the year that has passed since my last post, I have had times of great happiness, but they have occurred in the context of being truly lost, overworked, sleepless, and even despairing. As I stood on the deck this morning — the cold air heavy with fog an undeniable sign that autumn is here, an unmistakable reminder of the winter that is coming — I felt a tiny dread, an echo of last year’s endless winter that broke my heart and presided over the utter disintegration of my personal life. This too, is what it means to be alive, a part of the “life’s rich pageant” to which my father increasingly refers.

One month ago I passed my comprehensive exams and national boards, which means that I have graduated and am now a Certified Nurse-Midwife, just under five years after I first realized that I was not going to work in public health forever and began hatching a plan for change. In the past year, I have provided prenatal and gynecologic care to hundreds of women, attended to the health of their newborns, lost track of the number of births I witnessed, welcomed several dozen babies into my hands. I learned how to diagnose and treat infection, how to repair lacerated skin and muscle, how to prevent death by hemorrhage, how to dislodge a baby stuck behind the pelvis, how to revive a baby who comes into the world and does not breathe. I began to learn how to tell a woman that the pregnancy she thought was healthy is now over, how to tell her that her diagnosis of infection means her husband has been unfaithful, how to tell her that she may have cancer. There was rarely a day in which I didn’t make a mistake; thankfully these usually didn’t cause irreparable damage.

I am awaiting the arrival of my license to practice midwifery in New York, regrouping mentally and physically, and looking for work.

In the course of finishing my midwifery training, I was required to do some writing by my program director, lest the entire period pass without deliberate self-reflection. I now have time to look back over this writing and I am struck by how much sadness and fear it evinces, instead of the joy you might expect from someone finally learning the craft that she had admired for so long. Perhaps this is a product of the innate seriousness of the work of caring for women and babies. Perhaps it is a product of the shadow that came over my life when I learned how to care for strangers but forgot how to care for those closest to me. It certainly reflects my ongoing criticism of the damaging institutionalization of maternity care, which does everything in its power to remove power and agency from women and transfer it to the institution itself. I hope that it doesn’t reflect taking for granted the happy outcomes — a healthy woman, a healthy baby — because I have learned how far from certain these outcomes are.

So I will begin posting some of that writing here, and maybe you’ll tell me what you see in it. Next time I’ll start, at least, on a high note: the final birth I attended as a student.

“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.

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?

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!

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?

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.