Thursday, August 11, 2011

The Candor of Death

Last night we were met at the door of San Therese hospital by the candor of Haiti’s infant mortality rate. We arrived around 7:30pm or so for our 11 hour shift. There was a woman in labor who, within moments, was pushing out her baby. The student midwives were not ready, and I scrambled to find supplies while the others delivered the baby. While gathering instruments we needed, I uncovered a crumpled chux on one of the delivery tables. I opened it up to see if it was usable and found a full term dead baby. In my hurry to deal with the delivery, I was unexpecting and vulnerable. It took me by surprise. But the midwives were working, business as usual. No one seemed very interested in the body. I asked the student midwife what we were going to do with the body. She didn’t have an articulate response. Finally someone, the  night janitor, realized that we needed a box for the body. She ran and reappeared wth one. We placed the baby in the box and of course the question, then what? We needed to keep the baby here until morning until the janitor would dispose of it in the appropriate way.
This is life and death in the maternity ward. I would later learn from the day janitor  that he buries 2, sometimes 3, stillborn babies a day. The math is too horrific to calculate. The midwives deal with this tragedy with calm and flat affect. They are unemotional. They seem disconnected from the possibility that this small body represents more than the products of an ill-conceived conception. This must be the callous of years of death’s relentless mocking. Even with the best of nights, there is the reminder that babies die here on far too regular a basis.
The precipitous birth of the live baby is finally under control and the baby is dressed and weighed. The live baby also is left on the scale for a long time without an attentive eye. I occasionally go over to check the baby and make sure that the quiet is from sleep and not death’s gnarly grip. The mother is dressed and readied to go into the postpartum room.
Another woman has come into the labor room with a referral from an outlying clinic. She is in labor. We have a hard time understanding the French translation of her referral note. Our interpreter insists that it says that the baby is lying up against the mother’s back, a simple posterior presentation. Susan is sure that she sees the French word for twins on the paper. It is all for naught because the student midwife cannot find the baby’s heart tones. Susan tries too and is unsuccessful. We are here to teach the student’s so I ask Marie Carmen, what does she think? What would she do now? What she thinks is best is to wait until the baby is born and to tell the mother then. I disagree, telling her that if her baby is dead, that we must prepare the mother as soon as we know. If the student has difficulty finding the heart tones, they should always ask the senior midwife for help. Marie Carmen and Susan tried one last time to find heartbeat, met again by the mocking silence of death. The staff midwives decided to send this woman on to Cange, to the Zamni Lasante hospital there. She had a ride , otherwise the transfer would not have been an option. We would not bear witness to her grief.
The second baby of the night was born precipitously in the antenatal room. A student ran out saying that the baby had been born. We all ran in to help and to see the baby that had been born so quickly. When we approached the bed, the baby was on the mother’s abdomen but not breathing. The baby remained quiet and limp, eyes wide, even with our immediate tactile stimulation. I asked for an ambu bag and one of the students ran back to the delivery room to get it. The hospital has no oxygen, so the resuscitation effort would simply consist of forcing room air into the baby. The ambu bag arrived and I quickly set to reviving the baby. Even though the baby’s heart rate remained strong, the baby did not perk up as I had expected. It was hard to say why this baby was having such a hard transition since no one had actually seen the birth take place. Had the baby inhaled amniotic fluid on the way out? Was there meconium? Was this baby infected? I continued bagging the baby for what seemed like a long time, repositioning the mask, the baby, asking for a better ambu bag. Long enough to begin contemplating next steps. There was no oxygen, no pediatricians, no NICU to fall back on. This baby would either live or die right here in front of us. I occasionally stopped the resuscitation effort to stimulate the baby again. We were beginning to see the barest of muscle tone and an occasional small cry. A stethoscope appeared and we were able to hear breath passing, though labored, through the baby’s lungs. The baby had classic signs of difficulty breathing: grunting, flaring, retractions.
Since the baby, a girl, was breathing on her own, we decided to stop the resuscitation. She was out of the danger zone but the next moments would reveal whether she could make it on her own. She remained stable by Haiti standards. In the US, this baby would have been immediately whisked away for resuscitation and continuous observation. The student midwives did a good job of helping out, but observed with an air of bearing witness as opposed to the heroic obligations that drove Susan and me to act. The baby settled quietly onto the mother’s chest and I told one of the students to check the baby closely for the next hour. She should check the heartbeat and respirations every 15 minutes, then check in with me after an hour. If anything changed, she should also let me know.
A quiet calm settled onto the Maternitè around midnight. I laid down on the cement floor outside of the ward on a yoga mat that Susan and I brought from the orphanage. I told Susan that I was too wired to sleep. She told me later that I was snoring within 15 minutes. I awoke sometime later to find a laboring woman sprawled on the floor across from me. She was on her back, heavy in labor, complaining that she was dying with each contraction. She was accompanied by a shadow sitting next to her, her mother I had assumed. When I heard the American accent of Susan’s creole, I realized that she had moved over to support this woman in her labor. As she sounded pushy, we moved her over to the labor ward. A fifth timer, with 2 living children, I was surprised that it was taking her so long to push. Susan suspected a posterior presentation because of the amount and location of the woman’s pain. She continued to often say that she was dying, which is disturbing in a country where that is a distinct possibility. Her baby was born, without event, bringing us to three live babies for the evening.
At 4am, the praying began. From the depths of the darkened antepartum room, we could here gospel singing and the sounds of a female pastor calling upon God and Jesus to remember them in their suffering. The singing was beautiful and eerie, wafting up from the depths of Haitian spirituality. All 10 women in the antepartum seemed to singing in unison, in harmony, interrupted by the intermittent wail of a contraction. I got up from the yoga mat and watched through the half open, Dutch door for a while. The pastor was walking up and down the aisle between the rows of beds, calling on Jesus in her supplication for redemption. The women were calm and peaceful, obviously knowing the lyrics from years of Haitian church-going.
As the light of day brightened the courtyard of the hospital, a small, old man shuffled in to begin his day’s work. He is the janitor. He emptied the trash barrels into his wheel barrel and picked up the bloodied, medical trash strewn about by the nocturnal scavenging dogs. I knew that this was the man who would dispose of our baby in the box on the labor room floor. I was determined to see this process.
Eddy, for that is his name, loaded the box up on top of the rest of the trash in his wheel barrel. I followed him out of the hospital, explaining that I just wanted to see what he did with the dead baby. He was patient and kind with me, perhaps I was the only “Blan” he had ever spoken to. He loaded up his pick ax and shovel onto the wheel barrel and I followed him out to the back of the hospital. We followed a small dirt trail to the area where he burned the trash every day. The piles of plastics and IV detritus was encircled by a lush grove of greenery and vines. Eddy parked his load and walked into the grove. He selected a spot and began to dig. I asked him if he did this everyday. Yes, there are 2, sometimes 3, every day. The pick ax was almost as big as him and he swung and swung until a small, rectangular grave had been dug. I helped him by bringing over the box with the dead baby. I asked him if he had children. He said only one— the other he had already buried. The current box that the baby was in was too large, so he found a smaller one amongst the rubble and placed the baby inside. I offered him my gloves since his had ripped. I was called away at this point, but felt content with my understanding of the process. The fertile soil of the lush grove entombed hundreds of dead babies each year.

I said goodbye to the woman in postpartum whose baby we had resuscitated. The baby was breathing perfectly now and the mother was all smiles. The ride home on the moto taxi was cool and breezy. I held on to Susan, saying that we had survived the night. Tonight we will be at the hospital again.

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