29. Whatever ...

When I was a practising obstetrician, helping women to prepare for childbirth was an important part of the job. This especially applies to the birth of the first child, which Natural Selection, in a harsh and impassive demonstration of its single-mindedness, has made by far the toughest.

Being a left-leaning, feminist, empathic sort of person, with only mild Asperger’s syndrome, I might easily have been tempted to recommend that women in labour listen to whale music in a giant tub of yoghurt under an oak tree with their partners messily massaging the small of their back until second stage kicks in. 

Had it not been for our first childbirth.

Jenny took five days to decide to come out above rather than below the bladder. The emergency C-section under general anaesthetic has been a familiar shipwreck of the dreams of far too many couples.

At first, I used to believe that this meant the need for more intense childbirth preparations, particularly in relation to managing one’s expectations. Then a weird thing happened. I noticed that those least likely to make such preparations – teenagers from less privileged backgrounds – often had remarkably good labours. When asked in advance what their birth plan was, such a person might typically say, “Whatever …”

Eventually, I stumbled on the obvious answer: It is all about dealing with stress and anxiety. More stress: more adrenaline. More adrenaline: more pain; tighter pelvis; weaker contractions.

More chilled: more natural oxytocin; more compliant pelvis; stronger contractions. More 'whatever'. Childbirth preparation helps, but it does so especially in proportion to the amount it helps you take control, at the same time as relaxing and let it happen. 
(Easy for a man to say.)

(For a man to write, actually. Asperger’s kicking in.)

So I ended up spending a lot of time explaining to first-time mums the need to chill out at home as long as possible, (as long as all was well and the baby was moving normally). Have a bath. Have something to eat. Go for a walk. Watch an East-Enders box set. OK, perhaps not East Enders. Anyway, chill. Have the transport ready then only get in it when you reach the “Get this baby out!” stage.

It shows what an English city-dweller I am, than in all these considerations, it never struck me to doubt that the transport would always be there. Not just the car, but someone to drive it, fuel to put in it, money to pay for it, and a short road to drive it along.

This set of thoughts has been flashing through my head because of a recent email from Berega: A bus and car crash near the hospital has led to 49 admissions, many of them critical, in a hospital whose resources are already badly overstretched.

In Tanzania, there are no tarred roads in rural areas. Just dirt roads which get flooded and scarred by the ironic flashes of angry waters through this parched landscape.

In 2010, there were 1.24 million deaths on the world’s roads, most of them occurring in countries like Tanzania, where overcrowded transport, packed with the poor, the needy and the pregnant, recklessly charges towards its destination; or sometimes its destiny.

In the territory of Berega Hospital, the problem is made worse by the unaffordability of cars. Bikes and motor bikes are the only ways to make a longer journey. And they are by no means always satisfactory.

                                       

 

    

My mind goes back to two of the most disturbing memories of my time at Berega – both of them relating to transport rather than health. One was of the woman who came from a distant village on a motorbike having been in labour for five days. For the last three days, the baby’s head had been out, and the body still in. In that state she managed the unimaginable middle passenger journey to reach help. More unimaginable still was the woman who arrived too late, having bled just too much on the bumpy ride in. Her body was taken back to her village and her family, a lifeless middle passenger on a bumpy ride back.

When I went to Tanzania, I had imagined that health services were the central plank in the strategy for saving mothers’ lives. But just as the causes of death are complex, so are the solutions. Fabulous maternity services that no-one can reach, that no-one can afford, will save no-one's lives. Whatever we do, it has to involve community development. It has to address, more urgently perhaps than any health priority, those issues which prevent access to care: for instance poverty, lack of female education, and poor transport.

Whatever solutions exist must, (the WHO now tells us), be first articulated by the village women themselves, if they are to be pursued sustainably:

http://apps.who.int/iris/bitstream/10665/127939/1/9789241507271_eng.pdf?ua=1

Whatever we do, we must get out into communities and engage with pregnant women and their sisters and their carers, if we do not want them to become next year’s mortality statistics. Whatever these mums feel might be the solutions, be it to poverty or education or transport, those are the directions in which we must travel.

Whatever.