Hello dear community, I would like to bring you to work with me at Nyahuka Health Center (NHC), the level IV government-funded health center I work at, where we deliver roughly 3,500-4,000 babies a year! Look straight ahead; the orange building is our maternity ward.
You can read this short article that gives a great description of the Ugandan healthcare system, but mostly, just know a level IV health clinic is a step below a hospital AND includes an operating room (aka theatre). Here it is, with the resuscitation corner in the far right:
Mothers who know they need a c-section or women who have complicated labor will get referred to us from level III health centers across Bundibugyo district, including refugees from Congo.
My job here is to receive the baby and teach/perform basic newborn resuscitation if needed. Here is a standard set-up with one ambu-bag, sterile gloves, baby blankets, a bulb suction, and a few ties for the umbilical cord. As you can see, we work with minimal equipment in a tight space.
I’d say about 60% of the babies born in the theatre need resuscitation. Every resuscitation I've attended in theatre has gone well, thank God for that!
Let's walk back now to the maternity building and introduce a typical patient scenario that would land a mother to check-in to our ward below:
A mother feels her first contractions at home in her village. She walks 10 minutes to her closest level III health facility to give birth. Her water ruptures and the contractions get stronger. Perhaps her baby is in an unfavorable position, has a low heart rate, her cervix is swollen or not dilating, or she starts to run a fever. At this point, the midwife would refer her to us (often, the referral is made much later due to knowledge gaps). Money is scarce so the mother may choose to walk the distance to us. Or she may wait until the morning to avoid traveling in the dark. But often she arrives riding on the back of a motorcycle, sandwiched between the driver and her support person. The delay in getting to us puts her on a path known as “too little too late,” (meaning insufficient medical care received too late) and can often later be traced to poor outcomes. Everything in our maternity ward happens in a communal environment, except for the birth. There is a small labor room (pictured below) with two dilapidated beds.
We see a mixture of normal and abnormal cases, and because of inadequate and minimal fetal monitoring, there is a significant amount of newborn resuscitation occurring in our labor ward too. The good thing is that MOST of the babies perk right up after a minute or so of receiving breaths (and that's even without having oxygen available)! When a woman comes to have her baby, she is expected to bring:
sterile gloves for the health workers
baby blankets
a tarp to birth on
sheets
a clean razor to cut the umbilical cord
a basin for her to urinate in and for us to deposit the placenta in
pads
food and drink
Can you picture preparing to give birth in the space above? Despite the environment, we treat each woman with dignity and respect. After you have your baby, you walk over to the postpartum room, where you get a bed frame, but a mattress is not guaranteed, so it’s BYOM. Below the midwife in the national uniform (white dress) is about to announce for all visitors to clear off the floor so we can fit between the beds and make rounds.
In America, as a friend or family member supporting a woman through labor, you are not tasked with much. But here, it is your job to bring them food, water, clean up any spills on the ground, empty and clean the basin of urine/blood/vomit, bathe the baby, run to the pharmacy to buy medicine or IV’s when they are out of stock, etc. It is a busy, selfless job- but as you can see... newborns bring joy.
There isn’t a lot of “extra” that the Ugandan government provides here on the border. Midwives are scheduled to work an 8-hour shift, usually with a max of one other person and a doctor on-call. Employees often call out to attend funerals, school, or for sickness- which means the maternity ward is always understaffed, and they are thankful to have me and any nursing student volunteers there.
Most of my coworkers are hard-working, caring, and do the best they possibly can. They also laugh and bring humor into the workplace, which keeps them and the team strong. I've had opportunities to pray with my coworkers and patients during times of overwhelm and fear. It's an environment that highlights our moment-by-moment need for Jesus.
During a dayshift, the midwife oversees a few laboring patients, a postpartum ward with about 24 recovering mothers/babies, a high-risk pregnancy unit with about 4-10 patients, and all walk-in postpartum mothers seeking care for themselves or their sick newborns (typically there is a line of mothers).
This is an overwhelming amount of patients for 1 or 2 people! The goal is NOT high-quality care for EVERY patient. That is simply, impossible in this environment. The goal is to make sure people don't deteriorate. To make sure they survive. I had to shift my values to be able to function and work at a place like this and have been coached to approach the nursing shift more as if it were a mass casualty situation and less from a typical American nursing perspective. This means I help screen for the most vulnerable patients and spend my shift caring for them. Stable people are often ignored. In some ways, it’s how I imagine Civil War nursing to have been, minus the smiles:
My coworker wore this shirt to our weekly maternal and neonatal death review meeting. Every Monday, the maternity staff and clinic doctors carefully look over patient charts and discuss where the gaps in care are seen. Did the mother delay coming to the health center? Did we have life-saving equipment available and functioning? Was it a knowledge gap among the healthcare workers? (A man selling local greens is seen in this picture below, as we each bought a bundle for dinner that night).
Approximately 800 women died every day in Uganda (in 2020) from preventable causes related to pregnancy and childbirth. The local greeting to someone who just gave birth here is "Webale Kwejuna" translated, "Thank you for surviving childbirth." These women who are losing their lives are friends, neighbors, wives, students, and precious daughters of God. When you take away a mother, everyone around her orbit crumbles as well. I am thankful for my part-time work that allows me to be a part of a team that, despite monumental obstacles, strives to save lives. Uganda is actively trying to improve its poor maternal/neonatal mortality rates, and these weekly meetings are a part of that. I also learn a lot about local culture and the interplay with how this informs our patients' healthcare decisions. Here is a tiny glimpse into the social history of a newborn death review this week: “Patient is the fourth new wife of a polygamous marriage and dreamt her husband’s other wives were jealous and bewitching her. She states they ‘stole the baby out of her while she slept at night.’ Instead of the patient bringing her concerning ultrasound results back to the health center, she went home to settle the issue using witchcraft and returned to the clinic with absent fetal heart tones.” *a few details changed to protect patient privacy This gives you a sense of the layers to which these meetings reveal, including the spiritual climate of where we are. This is not a patient with psychiatric issues. This is a normal part of the culture here and provided an hour of discussion and analysis, eventually landing on multiple gaps in care both on the patient and provider side. This concludes your tour! Thanks for joining in, and I hope this gives you a better picture of the medical side of our ministry here in Western Uganda. Here is a healthy set of twins to bid you farewell, straight from the theatre, both resuscitated and wrapped in white, held by their grandmothers!
***Pictures taken with permission***
***Also important to note: I work legally in Uganda, with a work permit, and a Ugandan nursing license administered by The Uganda Nurses and Midwives Council