Safari Njema

In an effort to create some positive memories for t., who has been struggling to adjust here, we took a short trip to the Serengeti National Park this past weekend. Everyone had a great time, and we were even able to bring Esther along, the orphan who has been helping us with the kids for the past couple of weeks. At the lodge she enjoyed her first ever hot shower (I was pretty excited about it myself) and her first visit to the Serengeti. Thankfully the park is free for Tanzanian citizens, so it is accessible to all the kids, if they can only get there and find a vehicle to ride in...it wouldn't really be safe to just walk around, and I think it is not permitted anyway...enoy some of the pictures! This may be the last post until we get home. We leave tomorrow.
Asante sana, Tanzania. We love you.

Take Opportunities to Exhibit Grace, Part 2

After Dr. C heard what happened, he invited the girl's father into the privacy of his small home and listened to the story, I am told he said the following to the girl's father: “I'm sorry she doesn't know how to behave properly. Why don't you send her here [to school at the City of Hope—this girl is not in school at all] so that we can teach her?”

Z told me this story as we had chai together the next morning. His comment was, “You know, Dr. C. responds in such a Godly way.” Then Z told me another similar story. He said, “A few months ago a boy was caught stealing maize from our cornfield. He had only a small amount, maybe six ears. He was almost through the fence when he was caught and brought to Dr. C. You know what he said to this boy? He said, 'I'm sorry you do not know to ask. You don't have to steal from us. Stealing is wrong. (That is not a given in this culture.) Next time you are hungry, just come and ask for food.' And he gave the boy even more maize and some other things and let him go!” Z concluded his story with an absolutely beautiful smile.

Philemon teaches a similar lesson. Onesimus the slave has run away from his owner, Philemon, whom Paul knows to be a Christian. But then in Rome, Onesimus then meets Paul, becomes a Christian—a new man through transformation by the gospel. He also becomes a brother in arms to Paul, serving him while he is in prison. Paul knows that between Onesimus and Philemon, both professing Christians, there must now be reconciliation, so he writes the letter to Philemon, saying that Onesimus must ask forgiveness for running away, and that Philemon must forgive him and take him back with grace—and not just as a slave, but as an equal—a brother in Christ. Surely this is hard for both men, but for both of them it is an opportunity to grow in Christian virtue. Paul sees this, and behaves accordingly. He takes it not only as an opportunity for reconciliation, but also an opportunity for Onesimus to learn the humility of admitting wrong, taking responsibility, begging forgiveness, and attempting to make amends, and an opportunity for Philemon to learn the discipline of genuine active forgiveness and the lesson of unity and equality in Christ—equality of a learned man with slave—a totally counter-cultural lesson.

All of my adult life, even as I have had many positions of leadership, I have feared correction, conflict resolution, and confrontation. It's hard to tell people that they are wrong. But today I see it in a new light. Every conflict resolution, every correction, every confrontation is an opportunity for discipleship. It is an opportunity to exhibit grace. It is an opportunity to be Christ. For all parties, it is an opportunity to grow closer to Christ, and it is an opportunity for me to help them in those steps. So I resolve to strive to see these things this way when they came up. Clearly Paul did. Clearly Dr. C. does. As I see it, the biggest challenge for me will be to learn to do this as a parent. It is one thing to do it for an adult who can see that you are showing mercy, and focusing on demonstrating the gospel instead of focusing on making them behave correctly. It is another thing to do it for a rebellious four year old who doesn't even recognize (on a conscious level) the grace he is being shown.

Lord, thank you for teaching me this lesson. Help me as a leader and as a father to take each instance of correction as an opportunity to exhibit grace while still acknowledging the wrong. That's what you do for me. Help me do it for others. I need your help, because this is going to be hard...

Photo Journal of the little world of t. and w.

So, our children can't write blog updates yet, but I'm sure they would love to share with you a little bit about what life has been like for them here. I will post pictures until my patience for the internet wears out completely.

In general t. and w. enjoy lots of playing inside and out, although t. is still hesitant to go outside when the children here are on recess or if it is after school. There are just too many of them for him to feel completely secure, and they enjoy calling his name repeatedly whether he ignores them or not. Sometimes when they call his name he will yell “I'm too busy!!!!!” or “I have germs!!!!” and run away.

Anything in italics is t's exact description of the photo.

Farm animals are a part of the agriculture
program they have for the orphans.

Me and w are chasing the pigs.

w. is swinging.



I am sorting the beans. The children here work the fields
before school and on Fridays.
They are currently harvesting beans and maize.




Did you know that boy was, like, sharing his cars?



I am peeling potatoes. The children are constantly "helping" Margaret and Miriam with the cooking.

It may be hard to see but this is the result of
a "nairobi fly" landing on the skin and walking around.
It secretes a trail that is irritating to the skin.

I was holding a chick. I saw him in a family!

W is washing with mommy.

W. gets a kiswahili lesson from Mr. Ben

I am sitting on a mountain. Going "to the mountain"
 is by far t's favorite activity.

Not unlike an animal at the zoo...

A favorite activity among all the children is to push the stroller.

After a little too much freedom with some crayons,
t. removes the evidence.

w. is obsessed with writing, drawing and painting on herself.

Far more exciting than the stroller is the wheelbarrow.
It goes a lot faster, too.

t. helped harvest a bunch of banannas
from the tree behind our house.

Evening ritual-Daddy reads Black Beauty
and t. falls asleep on the couch.

Snacking on the stoop.

The girls from the children's home love to play with t and w.

Who doesn't love a game of magnet fishing for bottlecaps?

Despite the fact that we eat 3 amazing meals a day, w. makes
 her way to the children's home as often as she can and
steals ugali from the children at dinner. (cornmeal mash)

Movie night! Guess what they are watching? Laurel and Hardy!

The rains have finally come and created irresistable mud puddles.

Post-mudbath bath.

t and his best friend, Esther.

This is what happens when a 1 year old is
supposedly napping.We can't decide if she looks
more like smurfette or the incredible hulk.

Well, after about 4 hours I am pretty tired of posting. I will probably put up more pictures after we get home, when the internet is more friendly.

I should thank Esther (sitting on the tire with t.) for without her there is no way I could have done this today. Asante sana, Esther.

Take Opportunities to Exhibit Grace

I am always on the look out for lessons to be learned from those who have gone before me. This past week, by the confluence of events I will describe here and the reading of Philemon in my daily Bible study, I was taught a beautiful lesson—one I hope I shall never forget.

It had been another hard day of travel. We had gone to see the government again. (Thankfully, we now have in hand the legal papers to open the hospital!) The van rocked back and forth as Zecharia navigated the foot deep ruts in the road spawned by the recent rains. Imani and I reclined in back seats of the van, our feet propped on piles of supplies. We were all trail worn. We were running late. I had had to make the unpopular decision to abandon the remainder of our errands in order to arrive home before dark (thus depriving poor Baba of his dinner).

Ahadi and her new tiny baby rattled around in the front seat. We had picked them up from the hospital on our way home. She recently had a C-section and is recovering well. It awes me to watch her bring home a premature (under five pounds) infant to a mud hut where she has minimal belongings and essentially no resources. I know for a fact that she doesn't have ten dollars to her name. In her little home she will care for her infant and give him her strength in the coming weeks. Jolting from the bumps with a new ten inch scar on her abdomen (it's got to hurt), she doesn't even act like there is any hardship about it. She smiles so happily with her miraculous baby boy. When I think of what copious resources (easily a hundred thousand dollars) a similar case in America would subsume...social workers, ultrasounds, five thousand dollars a night for the hospital, neonatal intensive care units (or as my friend calls them: more intensive than careful units). What does Ahadi have? One blanket. Enough food and tea for the next day. It's hard to wrap my head around why the world is the way it is. Don't feel guilty for all that you have, that is not my intention. But if you will, please remember to pray for her, for she will need it. And bear in mind that she and her son are rich in ways that you, dear American, are not...

We were only a mile or two from home when a tremendous crack tore through the van. Shattered glass showered Imani and I (he got the worst of it). Instinctively I got on my toes and crouched low in the van, wondering if someone was shooting at us. A rock the size of a baseball skittered over the van floor and clunked into the well by the sliding door. Someone had a thrown a rock through our window! As the van skidded to a halt in the sand, Zecharia was out of the driver's seat and running after the vandals before the vehicle even stopped. Like an bailing fighter pilot, he had just jerked the emergency brake and jumped!

By the time I got my bearings and scanned the horizon for threats, Z was interrogating a ten year old boy by the side of the road. Already a group of witnesses was gathering. The youth had in fact seen the whole thing, and he knew the girls that had hurled the rock. He pointed to their house—the typical mud hut with a thatch roof. Not knowing how we were going to negotiate this, I agreed to go to the house and talk with the girls' parents. I wondered, “How do you handle vandalism in this context? How can we ask a family to replace a window knowing that it will cost as much as they make in a year? But people have to be held responsible for their crimes don't they?”

I knew we could call the police, and I knew that because we have a very good relationship with them and there were many eyewitnesses, they would take the case seriously, but what would happen to the little girl if we did that? Was that a tenable solution? Could we demand payment, even if it was in tiny increments? Should we just forgive the whole thing and write off the $200 loss? Wouldn't that just invite this kind of thing again? I didn't know what to do, but since Z said we should talk to the parents, I figured that was a good place to start. He actually did all the talking.

We learned that her brother actually goes to school here at City of Hope. Before long thirty people were engaged in the negotiations by the side of the road. The girls had disappeared. The parents did not argue. They were clearly distraught. They are wise enough to realize that the education of their children, which the City of Hope is providing, is perhaps their most valuable asset. The father agreed to come to City of Hope to talk to the director, Dr. C.

So what should we do? What would you do? Feel free to leave a comment.

to be continued...

African killer bees-all they're cracked up to bee?

Preparing the smoker.

Walking towards the hive, which is under the
tall tree at the far end of the shamba. (garden)

A few days ago I had a truly singular experience: I was attacked by killer bees... no kidding.

Recently it came to my attention that we have some beehives here at City of Hope, and that they had been unharvested for some time. Now, I have made some attempts at beekeeping at home, mostly with dismal results, but I am at least familiar enough with hives and bees to be able to figure out how to get the honey out. Honey would certainly be a welcome addition to our sometimes too healthy diet here, and the collection of it would be a welcome diversion on a Sunday afternoon.

I have heard that African bees can be on the aggressive side, and what is more, I had the good fortune of locating a couple of protective beekeeper's suits, so I decided to use one. One of my friends here heard I was going to collect the honey. His response was, “During the day?!” (Bees are more docile at night). I didn't want to bother with the hassle of not being able to see well, so I didn't want to wait for night. My answer to him was a confident, “Well, I have a beesuit, so what could go wrong? I'll be fine.” I said all this knowing that the African honey bee is infamous for its malevolence. We even refer to hostile bees in America as having become Africanized.

I carefully put on the suit, and even started a fire with cornstalks in a smoker—an apparatus that looks like a tin teapot with a bellows attached that is used to blow smoke onto a beehive. The smoke desensitizes their sense of smell (which they use to communicate) and has a soporific effect. I don't have any boots, but I was careful to put on shoes and socks, thinking this would be adequate. “They won't bother to seek out the only chink in my armor, and it's only a few square inches. It won't be a big deal even if they do sting me a few times there,” I thought. I couldn't have been more wrong.

To put things into perspective, in two summers of beekeeping at home, I never wore any protective clothing except sometimes gloves, and in total I was stung probably four times. Moreover, any time our docile Italian bees became at all agitated, all I had to do was walk fifty feet from the hive and they gave up totally.

I smoked the hive carefully for perhaps two minutes, a precaution I rarely took at home. The bees did not seem to be excited. Then I removed the lid from the hive. Now I know. What I later found on Wikipedia is true:

"African bees are characterized by greater defensiveness in established hives than European honey bees. They are more likely to attack a perceived threat and, when they do so, attack relentlessly in larger numbers. Also, they have been known to pursue their threat for over a mile. This aggressively protective behavior has been termed by scientists as hyper-defensive behavior. This defensiveness has earned them the nickname "killer bees," the aptness of which is debated. Over the decades, several deaths in the Americas have been attributed to African bees. The venom of an African bee is no more potent than that of a European honey bee, but since the former tends to sting in greater numbers, the number of deaths from them are greater than from the European honey bee. What makes Africanized honey bees more dangerous is that they are more easily provoked, quick to swarm, attack in greater numbers, and pursue their victims for greater distances. An Africanized bee colony can remain agitated longer and may attack up to a quarter of a mile away from the hive. One or two deaths per year in the US can be attributed to the African honey bee."  (A much larger but unknown number in Africa, to be sure.)

They found my ankles almost immediately. Now I've been stung by bees many times in my life. As a kid I was given a box of empty pill bottles and spent the summer collecting bees for “my collection.” I've never been afraid of them, and even when stung, I am apt to ignore it. One bee sting just doesn't bother me. But this was different. Within ten seconds my ankles started to burn. “How can they have found my ankles already?” I wondered. I looked down. My ankles were completely covered with bees.  Bee suits are made of material so tightly woven that is feels somewhat slick. The bees can hardly light on it, much less sting through it. Not so with my socks. There were a few hundred bees crawling on my suit. There were a few hundred more in bilateral bands around both my ankles—living anklets of angry bees. And they were fighting mad.  Now I've been close to a lot of infamous animals, (lions, cobras, mambas, crocodiles, hippos, a rugby player named Spike) but I've never seen raw agression like this.

After a few seconds I thought, “Okay, this is starting to hurt. I'll walk away and brush these guys off.” Brushing them off only made them more mad. Plus it killed some of them. When bees are killed, including if they die whilst stinging a victim, which they invariably do because their stingers are barbed--thus they lose a body part when they are swept away--they give off a chemical message indicating, “Danger!” Trying to brush them off just made it worse.

“Grrrrrr. This really hurts,” I said. Soon I was aggressively giving my ankles a dust bath by rubbing them firmly with dirt from the garden. “I can't believe how aggressive these things are,” I breathed. By now I was a hundred yards from the hive—unthinkably far from the hive for them to attack me in my mind, but instead of subsiding the assault only grew more intense. I must have had a thousand bees on the suit. They peppered the sides of the head covering incessantly. I sounded very much like popcorn when it's cooking on full heat. The kamikaze collisions were that frequent and that loud at such close range to my eardrums. And the buzzing was louder—almost deafening. It was very disconcerting. “No wonder people panic from these things. This is scary.” I thought.

By now I had washed them from my ankles with a bucket of wash water that someone had fortuitously left outside our house. My ankles throbbed. My mind was reeling from the incessant dive-bombing. I couldn't get help; who could help me? I couldn't even approach anyone to ask for help, since they would be attacked if I got close.

J., who had watched this whole escapade from a distance, provided me with a can of insecticide and another of repellant. I emptied both of them onto myself to little effect except that it gave me a headache. Soon I began to hear noise from the other side of the house. The bees had decided that I was difficult to kill and so had found others to assail. I later heard that as many as twenty people were stung—all hundreds of yards from the hive.

Eventually I enjoined J. to pass me a book out the window. I spent about an hour just sitting on a tire reading “A Brave New World,” waiting for the bees to go away and thinking that it's no surprise that horror movies have been made about these miniature kamikazes. When they were finally down to two or three assailants, I ran inside and shut the door. Thankfully none of them were able to follow me.

My ankles were a swollen mess when I peeled the suit off. I had less than ten square inches of unprotected skin. When I got to 100, I stopped trying to count the stings. I washed my feet and slathered my ankles in toothpaste, which I've heard helps. At home I know what weed to put on bee stings, but that weed doesn't grow here. I don't think the toothpaste helped. By dinner time I was shaking and vomiting violently. I had a fever. I was prostrate on the couch. J. looked it up. According to the Mayo Clinic website, bee envenomation from more than ten stings can cause these symptoms. It lasted most of the night—from ten square inches of skin! What if I hadn't had that suit on!

The next day I asked Baba about it. (He and his wife were both stung in the melee). “Yes,” he said. “They can even kill people. I know a man whose wife was killed by them. They were attacking her goat. She tried to save the goat and they attacked her. She died.” Wow. According to Wikipedia, the aptness of the name “killer bees” is debated by some. I don't find it debatable.

The next morning a five gallon bucket of honey appeared on the doorstep. My dear friend Zekaria had succeeded where I had not—and with no bee suit. He's the same guy who fixed the clutch with thread and superglue. He's kind of an African ninja. He just went in the night and was only stung a few times. Bless him and Baba both for not berating me for ignorantly plunging ahead when they had subtly warned me not to go in the daytime.

Birth in Tanzania (Part 4 of 4)

Hi!

Mother and child resting at home.



"Look!He's just a speck!" says T.

Once we got to the hospital, we had no choice but to leave Ahadi in their hands for a C-section. I had called ahead to tell them of the situation, but when we arrived they were not ready for a C-section. The doctor had not even been called. However, after about two hours of—dare I say fooling around?—they took her to surgery. Thankfully her contractions had nearly subsided and that two hours did not seem overly hard on her or the baby.

The sun was setting, and as it is inadvisable to travel in the dark, we had to leave trusting that she would be taken care of at the hospital and drive home. We sat mostly in silence hoping and praying the surgery would begin quickly and that mother and baby would survive.

As we pulled into the compound, Baba called the hospital to check in. According to the nurse who answered, the baby was out and they were closing the incision. A tremendous relief poured over us and we thanked God for His provision, protection and love.

A week later Ahadi brought home a beautiful baby boy named David. He's tiny—clearly a few weeks early, but is doing well. He is breastfeeding successfully and is clearly loved and adored by his mother—and so many others here at City of Hope. They were granted a heroes welcome upon their arrival and there has been a steady stream of visitors to Ahadi's house.

Thanks for all your prayers. Consider continuing to pray for Ahadi and David: the family situation is difficult and David still has many hurdles to overcome.

Public Hospital in Tanzania (Part 3 of 4)



Ahadi's house.

It was difficult for me (J.) to determine exactly what the furrowed brow might mean. Of course a doctor doesn't immediately verbalize all the potential things that could go wrong, without confirming them. As T. checked her cervix the second time I heard him whisper while looking up and away, the way people do when they are feeling something they can’t see, “Is that placenta?” He looked crestfallen.

My heart sank. And then began pounding. Although homebirths attended by qualified midwives and physicians are extremely safe, there are a few very rare, but very serious true obstetrical emergencies that cannot be handled completely during a home birth. Placental prolapse is one of them. Immediately I thought, we might lose this mama, and this baby. We were an hour away from the nearest hospital—and that is only if the van did not break down (if it even started), we were not stopped by a police check, there wasn’t a truck broken down in the middle of the road blocking our way or the occurrence of a host of other very common scenarios. I thought about the secondary effects of losing these patients. Would the community trust us? Would they still want us to work with the hospital? Would we look like quacks? I silently mouthed the words to T. “I am worried.” He mouthed back “Me too.”

T. decided it was not placenta, but things were still not normal at all. While he waited to observe he sent me to our house to get some things we would need if we were able to deliver the baby. I gathered bath towels, paper towels, embroidery floss (the best thing I could think of to tie off the cord) paper towels, scissors and rubber gloves. We didn’t have any sterile ones left (Ty had 2 pairs and they were reserved for him.) But I had already come into contact with some things that I shouldn’t have, so I grabbed the rubber gloves from the cleaning shelf.

I ran as fast as I could back to the hut. When I arrived things were already in motion to take Ahadi to the hospital. She was halfway to the van, navigating very uneven ground, walking in between two lazy napping cows. Damaria at her side, I grabbed her other arm and supported her as she walked. I was amazed that she could walk this far. She was past transition, fully dilated and pushing. And there she goes, determined and focused, walking to the van. The instinct of this mother to do what is best for her child must have been very strong, because I know from my own experience, that the instinct to stay put and go nowhere when in the last stages of labor is almost irresistible.

I had already been praying for this mama, for this baby, for this birth—but once I realized that even T. was worried and we had to transport to the hospital I began that really desperate kind of praying—the kind that goes like this, “Please God, help. Save this baby. Please please please. Help us get there in time! Help this van to start! Help us to make the right decisions! Help! HELP! HELP!!!” Not eloquent. But in these moments God is not asking for eloquence. He is asking for trust, faith dependence.

The first prayer was answered when the van started right up. We began barreling through the village at speeds I did not know the van could go. If I were not so worried about Ahadi I would have been terrified for my own life! What we did not need was a car accident on top of an obstetrical emergency. I thought, at this speed we are sure to hit something—a small animal, maybe a child. Lord help us! More simple, desperate prayers.

The van was hot. Ahadi sat directly in front of me perched on the edge of the bench seat, leaning back into my chest during contractions and leaning forward hanging onto the front seat in between them. We were sweating against one another. She grabbed my thigh and squeezed it during her contractions. I interpreted this as a request to massage her thighs, so I did what I could while trying to keep both of us from falling off the seat or hitting our heads on the roof of the van.

It was now about 5pm. It would take one hour to get to the hospital if nothing went wrong. I checked my watch and started counting the minutes. After we got off the compound and through the village we turned onto a small lane and parked in front of some “stores” that look like shacks. What on earth are we doing? Does everyone not know this is an emergency?

“What’s happening?” I asked. “We need fuel.” Was T’s answer. For goodness sake, could someone not have filled the tank an hour ago when we were contemplating transport? Good grief. I spied my watch impatiently as the minutes ticked by. I was concerned that this baby would start coming out hands first long before we arrived at the hospital.

Five minutes later we were off and running again. As soon as it was safe to do so (safe being a very relative term) Baba called the hospital and told them we were coming, and that we had a patient in need of an emergency c-section and to please be prepared for her arrival. We made it to the black top road in less than 30 minutes. Baba rolled through the police check shouting “We have a sick person. We have to get to the hospital!” only after offering the traditional requisite Swahili greetings. They waved us through. I could not imagine in the US begin pulled over for speeding to the hospital and greeting the officer with, “What is the news of the day? What is the news of work? How is your family? Good, good, fine, thank you…well, we have a sick person here and we need to get to the hospital…” My patience was really wearing thin.

I had a million questions for T. but I couldn’t ask him anything. I did not want to create fear in Ahadi or the rest of us for that matter. But I really had little idea of what might actually be happening, medically. All I could do was continue to pray, remind the friends to do the same, hold Ahadi, and tell her over and over that she was doing great, she was very brave, and God is with us. She said she knew that, and she was not afraid.

Mercifully, her contractions slowed. They almost stopped completely. I imagine her body was aware that optimal conditions for delivery were not present. Perhaps her body was trying to stop the baby from coming before it was in a good position. Perhaps it was God. Perhaps our bodies' amazing natural abilities come from God! I believe they do.

I scowled at every bicycle, truck and pedestrian that hardly cared that we were honking and flying down the middle of the road. No one seemed concerned at all that we were driving dangerously fast and not necessarily on our side of the road. I was thoroughly impressed with Baba’s driving. Another answered prayer--we didn’t hit anything, or anyone. Praise God.

As we drove a song came to mind, that I have heard the children here in church sing. The melody is beautiful and a little haunting, it sounds a little like a Gregorian chant. I did not know the words by heart, but I knew the meaning. The repeating line is “God answers prayer.” I began to hum in Ahadi’s ear. Damaria knew the words and sang along. We sang the song over and over until we arrived at the hospital.

We turned off the pavement onto a side street and then turned in the “parking lot” which was a mess of deep ruts, dirt potholes and bumps. It was like an off-roading demonstration park. These last huge bumps must have been so uncomfortable for Ahadi but she did not complain. T. and Baba jumped out and hurried into the hospital before the rest of us could get out of the van. Ahadi amazed me by her strength and composure.

Well, despite our phone call ahead, there was no doctor there and obviously they were not prepared to wheel her into the “theatre.” They directed us to the maternity ward for examination. I was really frustrated. I asked T., “What is going on?? Why isn’t she headed into surgery?” He was very calm and explained that they needed to do their own exam and assessment before they could decide what she needed. I granted this was reasonable, but couldn’t they see that T. is a doctor from America and of course he knows what she needs!! I tried hard to not be indignant and to respect the cultural differences, but it got harder and harder as I observed.

The nurse spent about 20 minutes on the phone, calling the doctor. First they couldn’t get her on the phone. Then they said she was at home without a vehicle and didn’t have a way to get to the hospital. Then they said we needed to go pick her up. It was a total runaround. None of it made sense to me. My fear and frustration were rising.

By this time Ahadi was laying on her side on an exam table in the maternity ward. The room was large and separated down the middle by sheets tied together. On the other side of the curtain there were about 12 women in various stages of labor. One had her newborn baby lying at her side. Most of them seemed fairly relaxed (it was hard to tell who the patients were and who the friends or family may have been) but one woman caught my eye right away. She was a young woman wearing only a kanga (wrap) around her waist, she knelt on the floor contracting, one hand supporting herself on the floor, the other hand slapping and rubbing herself on her lower back. She was moaning. I wanted to rush over to her and help her right away-and I would have, if I were not there for Ahadi. I didn’t want to leave Ahadi’s side. I couldn’t believe that in this room full of women this young mama was essentially laboring alone. She was rubbing her own back for crying out loud!

The midwife finally got off the phone and examined Ahadi. With no obvious tenderness or assurance, she performed a pelvic and abdominal exam and concluded “hand presentation. Transverse lie. Hand prolapse. Yes. And the baby is very small. Is she term?” I told her we thought she was 35 or 36 weeks. She commented again that the baby was very small. Now, so far I am not so impressed with the bedside manner of this midwife, but despite that, it is clear that she knows what she is doing. I feel confident that she will agree to proceed to c-section. The midwife worked with assurance and maybe some arrogance. But honestly, in situations like this, that is what I am looking for in a healthcare provider.

As she performed the exam Damaria and Esta were listening in on a conversation across the curtain, between the laboring young woman and her mother. The mama was vocalizing during her contractions and saying “I’m dying, I’m dying” (I know that sounds really dramatic, but it’s a very common thing for a laboring woman to express just before she gets to meet her baby…it can be an indication that the baby is very close to being born!) Her mother answered her “Stop complaining. Stop yelling. Can’t you see you are disturbing this woman who is suffering?” She was talking about Ahadi. Then she said “If you don’t stop disturbing others I will leave.” The mama continued her groaning. The grandmother left.

The midwife left and came back with some supplies. She put in an IV line and a catheter and started a saline drip. While she was preparing Ahadi for surgery, the laboring young woman crawled under the curtain and appeared on our side of the room. I gathered that this was the “delivery” room, and the other side was for laboring. She was working her way towards the table next to us. The midwife told her “Get up off the floor. Get on the table” the mother struggled. She couldn’t do it. This time the midwife raised her voice and spanked the mama on the backside (she was now naked). She insisted the woman get on the table. I wanted desperately to help her but I felt I could not leave Ahadi’s side. The mama slowly climbed up onto the table and stayed in the hands and knees position. She moaned and groaned and rubbed her own back. With one hand on Ahadi’s IV the midwife stretched out her other hand, spanked the mama on the back again and said “Get on your back!” The mother flipped over like a fish, and clutched the sides of the table.

I immediately found myself thankful, that despite the many problems of American hospital birth practices, it is to be deeply appreciated that laboring women in the US are generally treated with respect and dignity. I don’t think this kind of treatment would ever be tolerated in the US. Not for one second. And I don’t think the average person really has an appreciation for this aspect of our society. So next time you hear someone complaining that their hospital doesn’t allow candles or aromatherapy, remember this mama.

The midwife continued her work with Ahadi while keeping one eye on the mama in the next bed. Suddenly, the woman’s water broke and it sprayed across the room, hitting the curtain and running all over the table and floor. The mama was lying very still, just clutching the table. I wasn’t sure what was happening with her because my focus was still on Ahadi. A few minutes later a shiny wet baby literally shot out and landed, just barely, on the table between the mamas legs. The midwife grabbed a clamp, immediately cut the cord and scooped the baby up by its feet. She held the baby above her head, by the feet, for a couple minutes as she searched for some supplies. She then loosely swaddled the baby in the wrap the mother had been wearing and laid it in a rolling bassinet about 10 feet away. The new mother appeared relieved and exhausted. She immediately got up from the table and started shuffling back towards the other side of the room. She didn’t even glance at her baby. As she left our side of the room the midwife scolded, “Next time listen to me and get up on the table right away. This place is dirty. You can get AIDS crawling around on the floor like that.”

Thankful that this new baby arrived safe and sound, despite the odds, I wondered...would we get the same outcome for Ahadi?

Doctor in Tanzania (Part 2 of 4)

“These women, you know, they always deliver at home,” a local man told me (T.) confidently.  “You can just do it.”  He meant, deliver the baby here.

While J. was sitting with the mama I was trying to decide if I had the guts to deliver this baby in a mud hut with no supplies but gloves and a pair of scissors, and no system at all for emergency backup.  We are just now getting the registration for the hospital in order with the government.  There are a few things in the hospital, but as yet they are all in boxes because we have not yet had time to build shelving.  There is no electrical power, no operating room lights if there were, no drugs to speak of, and very little in the way of surgical instruments.

“I don't want to be in the position to be doing a C-section in mud hut with a flashlight and no proper instruments,” I muttered.  I don't think he heard me, but he read my hesitancy.

“It's not her first baby, everything will be fine,” he advised.

“You're probably right.  The chances of something going wrong are probably only about 1%,” I consoled myself.  If I had known then what I know now, I would have estimated the odds differently.  I had been told that her pregnancy was totally uncomplicated.  Later I found out otherwise.  I thought the baby seemed on the small size, and by dates (which were not at all definitive in this case) she was only about 35 week pregnant (two weeks to go still to be considered full term).  That is not so good all by itself, but the date of conception was very vague.  The baby seemed consistent with 35 weeks, but guessing gestational age (or size for that matter) based on how big a uterus feels in an inexact science at best.

“Oh we'd better just send her to the hospital,” I thought.  “We don't need a premature baby born in a mud hut.”  But I hated to do it—the expense, the hassle, the expectations of the villagers.  Reluctantly I woke Baba from his Sunday afternoon nap and made arrangements to take her in the van.  After last week's escapade with the authorities, I'm not about to drive without a driver's license.  I could ride along in case things moved too fast and she started to deliver in the van.  I gathered a few simple supplies, made arrangements for my kids, and climbed into the front seat alongside Baba.

As we pulled up to the hut (as close as we could get the van) J. came out looking worried.  “I don't think we have time to get there,” she reported.  “She's pushing and they [the contractions] are getting closer together.” 

“Well, I'll check her,” I responded.  Frankly, I was a little worried about how I was going to broach the subject of an internal exam with Ahadi.  Believe me, it's just different when you are in someone's home, and you know them personally, and you're also in a very conservative culture that is not your own.

The hut I entered was totally different from the one I had left thirty minutes before.  One sure way to tell if a woman is truly in labor is: if she doesn't care at all about who sees her naked, then she's definitely in labor.  At least that's true in this very conservative culture.  Ahadi had been understandably shy thirty minutes ago, but no longer.  Now it was easy to see that she didn't care what I saw.  So I examined her.  Between contractions she breathed, “T, am I going to be all right?”

“Sure you are.  Everything will be fine.  In Jesus' name.”

The exam felt weird.  And I haven't done obstetrics in five years.  She was fully dilated, but, “What is this big blob?” I wondered, being sure to keep my face totally composed.  A large homogenous mass was palpable.  “[Oh, no] is this placenta?”  I think I may have mistakenly actually said this out loud.  Having the placenta come out before the baby is very, very dangerous—almost universally fatal without very fast and drastic intervention (a C-section in under five minutes).  The baby needs to “breath” through the placenta or through it's lungs—these are the only two options.  If the placenta comes out first, it's no longer getting mother's oxygenated blood and passing it to the baby.  And obviously a baby still inside cannot breath air.  I squeezed the mass.  “No, it's just the bag of water,”  I concluded.  The bag of water preceding the baby in the birth canal was huge, totally obscuring further examination of the baby behind it.  It was actually starting to protrude; I even could see it bulging between contractions.  Usually these amniotic sacs burst well before this point, but not always.  This one couldn't hold much longer; as I said it was already to the point of external visibility.

I examined her belly again.  The baby seemed head down, but it was hard to say.  It could have still been breech.  Mostly the fetus just seemed small.  Her contractions were coming quite strongly and quickly now.  “What do I do?” I wondered.  I agreed that we were very unlikely to make it the hospital an hour away if things kept going the way they were going.  The baby's heart rate seemed OK (a sign of vitality), but I didn't have my preferred equipment for listening.  I couldn't be sure.  In fact I had just three days ago pulled the donated ultrasound machine out of the shipping container and started trying to get it running.  That endeavor was unsuccessful, though it does come on and boot up when provided with power (from the solar panels on the roof).  I don't know if it's missing a part or the problem is just that I can read neither the machine nor the manual.  They are both in German.  I need to get an English manual.  Again I wished that I had the ultrasound machine working and at hand.  It's sitting useless in our apartment, one of the few places with solar power.

She was fully dilated.  The bag of water was protruding.  She was contracting quickly and they were strong.  Certainly there was no turning back, labor could not be stopped.  Even if I was sure this baby was premature, there was not a thing that could be done to forestall the birth now.  And I agreed that it seemed unlikely that we could make it to the hospital before he came.  “Even a mud hut is better than a van on the side of a remote dirt road,” I thought.

“Alright, let's do it here,” I said.  Ahadi was relieved.  She didn't want to go to the hospital.  Since it was going to rupture any minute anyway, and because it was in the way of a proper exam, I ruptured the bag of water.  It was so far out I didn't even have to do it internally.  I just snipped it a bit with my dissecting scissors (one of I think five surgical instruments I brought with me).  The amniotic fluid gushed out onto my arm, feet, and pants.  And made a mud puddle where I was kneeling.

I examined her again.  What I felt was NOT what I was expecting.  “What is that?!” I wondered.  It didn't feel like the top of a baby's head at all.  “Good grief, what have I gotten myself into?”  I doubt my face was as composed as I was trying to make it. This is the furrowed expression that J. had picked up on.

Then it registered in my brain.  “Those are five little bones,” I realized to myself.  “And that thing right next to it is five more little bones.  They're either feet or hands, and both of them are there.  Any way you slice it, this is a strange presentation—a one in a thousand, or even more rare.  So much for my self- assurances of  “a one percent chance.”

I can't feel the head at all.  And I can feel two extremities—probably both feet or both hands.  But they're so far up there I can't tell which they are.  They were just tiny nubs palpated with the tips of my fingers.

Now I've never actually seen any of these rare fetal “malpresentations,” as they are called.  They are pretty rare—something like one in a thousand.  I don't know how many babies I've delivered, but it's nowhere near a thousand.  And back home, anything like this gets caught long before this stage and ends up getting solved with a Cesarean section early on—so there is less than a one in a thousand chance of discovering one of these rare cases.

But I had learned about them in training.  However it was totally theoretical.  I have no practical experience with them at all.  I haven't even delivered a breech baby.  In America, especially where I got my obstetrical training, almost all breech babies get a Cesarean section at the first sign of labor.  And the few breech deliveries I've encountered before in Africa were all in the presence of an experienced midwife whom I trusted.  She knew what she was doing—so I let her deliver them.

I thought to myself: “OK, there's breech.  And then there's breech with a foot sticking out.  And then there's breech with both feet sticking out.  I can't remember what those are actually called.”  I wished I had a textbook handy.  I'm not too proud to work with a textbook open—especially in cases of fairly rare things that I've never dealt with before.

I continued to try to remember lectures from years ago: “And all those breech presentations can be managed with the normal methods of delivery.  And there are a couple of maneuver’s you can use to help the baby come out.  And I can remember at least two of those.  But what if those were not feet but hands?  It kind of felt more like hands, but...  Can you get both hands at the same time?  I don't remember hearing anything about that.”  I examined her again to double check.  There were definitely two.  And I definitely could not feel the head above them.

The rumination continued.  I don't know if everyone does this, but I typically work through problems via an internal conversation with myself: “I can remember that you can get a 'hand' presentation with the hands above the head, but I'm not feeling a head there at this point.  I wonder if the baby is coming shoulder first?  I remember those usually get stuck.”

I have to admit, I wasn't positive what to do.  The baby seemed to be doing OK.  Mom seemed to be doing OK.  So I just encouraged and observed for a while. I sent J. to our house for towels, string, and a baby blanket while continuing observation. Ahadi  seemed a little scared at times.  At one point I actually sang her a song—and I am NOT a singer.  But I offered to sing her the same song I sing my daughter when she is falling asleep.  It's actually a bible verse, verbatim, set to music:

“Be on your guard, stand firm in the faith, be men of courage be strong. Do everything in love.”

She seemed to appreciate the song.  It's certainly the first time I've sung for a patient.  I don't think it's what anybody was expecting, but it seemed appropriate at the time.

After about an hour of contractions, which seemed to be getting less frequent, she really hadn't made any progress.  I was waiting to see if the labor would push the head (or butt) down into the pelvis, and thus possibly push the hands (or feet) out of the way.  But no luck.  There was still no round hard thing (head or butt) palpable at the upper pelvic rim.  Just these two little extremities.  Actually, it seemed that the past hour of labor had advanced them further down into the pelvis.  But they were still pretty far up there.  They were nowhere near where I might see them. But I could feel them better.  I felt one carefully between the sides of my fingers by rubbing my index and middle fingers together at their tips.

I felt the baby grasp my index finger!  It felt just like how a newborn baby grasps your finger if you place it in his palm.  (It's a reflex they have.)  The sensation was unmistakable.  I checked for the other extremity.  Yes, it was still there, and it too was a hand.  And still there was no round lump palpable above that.  Just two arms that were now partially extended!

I've never heard of this kind of fetal presentation, though I suppose it is a variation of the shoulder presentation.  To help you imagine it, this baby was trying to take a swan dive through the birth canal.  He was coming chest first, with head back and the front of his neck was holding him out of the pelvic brim on one side, and abdomen resting on the upper pelvic rim on the other side.  His arms, instead of being extended at his sides like in a true swan dive, were extended in front of him.

“Ahadi,” I said.  “I don't think you're baby can come out this way.  He is trying to put his arms out instead of his head out.  I think we had better take you to the hospital after all.  Don't worry, it's not an emergency and you don't need to be scared.  I don't want you to be scared.”  I was trying not to be scared myself.  I knew that the only way this baby could come out alive was via C-section.  The problem was that I didn't have the proper equipment to be assured that the baby was still doing OK in the mean time.  But then he did grab my finger...

We climbed into the van and sped off toward the hospital.  Baba actually used to have an ambition of being a race car driver.  He's a fast driver as it is, but he was now in top form.  It being Sunday afternoon, the dirt road was crowded with foot and bicycle traffic, with a rare car or truck.  Baba weaved through them with... alacrity?  Honestly, it was fairly terrifying.  We all prayed for Ahadi and the baby.  I don't know if I was the only one praying that the rest of us would arrive at the hospital in one piece.  But we did—after only one stop—we had no other choice—to buy twenty liters of diesel put into the van from a plastic cooking oil jug.

Doula in Tanzania (Part 1 of 4)

Yesterday afternoon I was puttering around waiting for Mr. Ben to collect us. (This term is used here to describe picking someone up, or meeting up with someone.) He had invited us to come see his house at 2pm. It was nearing 3:30 and I was beginning to think perhaps I had misunderstood, or maybe it was not a firm commitment. T. had been in a meeting most of the afternoon. T. came to me and said “I am pretty sure Ahadi is in labor. Do you want to go sit with her for a while and do your doula thing?”

Ahadi is a teacher here at the City of Hope private school. She approached us about attending her birth when we first arrived and word got around that I am a midwife. Of course, I am not, I am merely a doula-in-training, and I have explained this as best I can, but I don't think there is an equivalent profession in this area so I am not able to really make it clear. Babies are mostly born in their homes, attended by a traditionally trained midwife. In some cases, women use the government hospitals, where they are not charged anything.

To be perfectly honest, my immediate reaction was fear. Ty was willing and comfortable with delivering the baby in Ahadi's hut, but I was concerned that IF something were to go wrong, we would be thoroughly unequipped to handle it. The hospital as yet has no equipment in it—it would be impossible to do any kind of emergency surgery if there were a need. Even the sutures are buried in a shipping container and would not be easy to locate if we needed them. The responsibility of the lives of both mother and child weighed heavily on me. I stalled a little while and then T. encouraged me just to go sit with her, to see if she was in fact in active labor.

I grabbed my backpack, into which I threw my camera, a bottle of water, some cookies, gatorade powder, notebook, pen...I was thinking “this is a really lame doula kit! I really wish I had more to offer her” and then it came to mind, that what a woman in labor needs most from a doula, or friend, or mother, is a voice that speaks love and encouragement to her, and hands that touch and hold her. I had both of those, so I hurried right along.

Entering the hut was like stepping into a documentary film. Ahadi was kneeling on the floor, which is made of mud and dung, panting and groaning. Obviously contracting. Two of her friends, young teachers who had never given birth were sitting with her, looking a little bewildered but clearly offering the best support they could. I began to time the contractions-they were about 5 minutes apart. I wasn't really sure how to help Ahadi. I started rubbing her lower back during her contractions and I told her “let me know if you don't like this.” Every woman is different and some love to be touched and massaged during contractions and some don't.

Although Ahadi speaks english, she was definitely in "labor-land," the mystical place that women go in their minds while they are in active labor-and I wasn't sure if my english was being fully understood. At the next contraction she told Damaria in swahili, to tell me to keep rubbing her back. This gave me a momentary surge of confidence-although I was still entirely out of my element.

Ahadi's house is one half of a two-room mud house, rectangular in shape with no windows and only one small door. The house faces west and we were blessed to have the bright African sun pouring in through the door, which was open with a sheer curtain hanging across it. It was blowing in and out of the hut with the wind. Between contractions we chatted like women do—her friends told me she had cleaned the house from top to bottom that day, and even covered the walls with a coat of mud and dung. A fresh coat that was perfectly smooth and even, covering the sticks that were the structure of the house. It looked like brown stucco. I nodded knowingly and said, “yes, she is nesting! This is how we know a baby will come soon.” I explained about mama birds building their nests and the friends nodded comprehension. Against the far wall was a short bed with a foam mattress on it. On the floor was a very small piece of carpet remnant. There was a charcoal cooking stove, some pots, pans, and thermoses against one wall, and on the other, a plastic chair and small table. The room was very small, maybe 8x10. With us four women and T. inside, it was definitely crowded.

As Ahadi labored I wondered at her instinctive techniques for managing the pain and also for bringing the baby down. She started to do things completely naturally-some of which I have learned about only in books or in class. She stood between contractions and stomped from side to side, squatting in between stomps. She groaned in a deep meaningful way. She knelt, the squatted. She slapped her thighs. She didn't need me to tell her what to do.

She said she felt sick and I asked for a bowl. Just in time we were able to catch the vomit. Vomiting can be an indication of transition. I was a little concerned that this birth was going to come quickly, and we had not yet really made a decision about whether to keep here here or take her to the hospital, which is an hour away on a terrible road.

I called for T. he came and I told him her contractions were getting closer together, she had thrown up, she was acting like she wanted to bear down. I was pretty sure I heard some grunting during the last contraction and maybe she was already pushing.

With her permissoin, he checked her, grinned and happily announced that she was fully dilated. She asked if she could push and he told her, “you can push whenever you want to.”

Through her next contraction we observed her bag of waters bulging externally. He checked her cervix again. This time I detected in his brow a very slight furrow. So slight I thought maybe a mosquito had landed on his brow...

-J