Neonatal resuscitation. Before we moved to Africa, neither of us had resuscitated a newborn suffering the stress of difficult labor and delivery. Here, however, mastering this skill has proved invaluable. In fact, applying simple neonatal resuscitation efforts and witnessing remarkable results must count as one of the most satisfying moments in a physician’s career.
Here is what we have often seen: A baby, blue and appearing lifeless, is born after a long labor inside a sick mother. It isn’t breathing, and the pulse is very slow or undetectable.
In many under-resourced settings, such babies are put aside to, almost always, die.
But we have also seen how warming, drying, stimulation, and a few breaths with bag-mask ventilation are easily the difference between life and death for these babies. Those techniques can be learned in a course lasting less than 1 day, and the nurses at KCMC have embraced them with great enthusiasm—with dramatic results.
Devastating problem: OB fistula
The problem of OB fistula recently gained widespread attention in the international media; as a result, some effort is being made to address the problem. But, with as many as 3 million women suffering from this devastating condition, that effort has only scratched the surface of the problem.
The typical fistula patient in Tanzania. Consider an impoverished 17-year-old new mother, of short stature, who lives in a rural area and has no access to OB care. It’s likely that she delivered at home; perhaps she had the assistance of a lay midwife.
After labor that lasted for as long as 5 or 6 days, the woman delivered a dead, macerated fetus. Despite the risk, she did not die of PPH or infection, but she is left with a vesicovaginal or (less commonly) rectovaginal fistula. She leaks waste constantly.
More often than not, her husband then divorces her.
Her family and community shun her because of her constant wetness, her odor, and her status as a mother bereft of child. Associated problems, such as foot drop, infertility, amenorrhea, and debilitating skin excoriations, worsen her status as a pariah.
An especially horrifying case. One patient—she was in our care for longer than 16 months—was brought in by her family and abandoned at the casualty department. She was emaciated and near death. The skin on the buttocks had huge ulcerations down to muscle from pressure necrosis and chronic wetness. She had long ago given up hope of living. She had both a vesicovaginal fistula and a rectovaginal fistula, with extensive scarring and no identifiable urethra or cervix.
This woman underwent resuscitation and, once she was stable, diverting colostomy. After months of wound care and nutritional supplementation, she was able to undergo repair of the rectovaginal fistula. She is now ready for a urinary diversion procedure.
Many of our fistula patients are not as sick as this woman was upon presentation; their problem can be addressed with a 1- or 2-hour vaginal surgical procedure. Their equanimity and humility belie their suffering. They are, we think, the most beautiful and thankful of all patients. They deserve any attention that the world can give to them.
How we’ve been reimbursed
What we’ve described here establishes a context for the work we do, but our words give only a glimpse of the challenges of providing care in such a setting. Gaps in language and culture; corruption; apathy; and a shortage of nearly everything that we have come to consider necessary in the United States to practice medicine—all these make life in Moshi challenging and interesting.
After 2 years managing the women’s health collaboration program, we’ve barely scratched the surface of understanding what it means to work and live in this setting. What we hope is that our understanding, compassion, and usefulness will continue to grow as we experience more and more in this and similar settings.
We close by observing that the most important personal characteristics needed for a successful venture into global women’s health are, we believe, humility, patience, honesty, and courage. These qualities are slow to come by; for us, acquiring them will be a life’s work—they are not a welcoming party that greets you when you step off a plane in a distant land.