G9 P7 3A

All was not lost and there was really no reason to be upset; after all this was her first pregnancy and she was still young. This was the sentiment expressed by the relatives of an 18 year old girl with eclampsia (seizures) who delivered twins, one of whom had been still born; the other had died two days later. After seven and half months of carrying the twins, it appeared a period of grieving for her losses was not a luxury afforded to her or something that has much place in a society where women expect only a proportion of their pregnancies to have a successful outcome and where surviving pregnancy itself is by no means guaranteed.

On Fridays I see patients sent over from the antenatal clinic run by the two midwives. As with all things in life, medicine is full of abbreviations. In obstetrics G refers to Gravidity (the number of times a woman has been pregnant) and P refers to Parity (the number of times a woman has delivered after 20-24weeks) with pregnancies ending before this time including miscarriage denoted with a “+1 or 2”. For example, a woman pregnant for the 3^rd time with 1 child and 1 previous miscarriage would be noted as G3 P1+1 (a relatively common situation in the UK). One recent patient in clinic came with abbreviation G9 P7 3A. The extra ‘A’ was new to me but I quickly learnt that the midwives used this to convey how many of the patient’s children were still alive. In the UK one assumes that a woman’s children are alive unless anything is written to the contrary. However, here it appears the assumption is that some of your children will have died and the question is how many. So the short abbreviation “G9 P7 3A” in fact represents an untold tragedy whereby  the woman is now pregnant for the ninth time, has given birth to 7 children, only 3 of which are alive. This is not far from average. The human side to such abbreviations is seen readily on the children’s ward. At 6.30pm yesterday, I was called to see a 2 year old who had just been brought in.  Although his mother stated the only problem to be ‘generalised body pain’, one look at the child, who was frantically gasping for breath, indicated his condition was critical. Sadly without the facilities of oxygen or intubation (to breathe for him) he was not long for this world. At 6.58pm there was a new child on the same bed waiting to be seen, the body of the first child had been moved to the end of the ward and wrapped in a sheet, and the father of that first child was having a frank discussion with the nurse in charge about how quickly they could have his corpse for burial. Perhaps the most upsetting aspect is that this is ‘normal’; engrained and expected. There is little interruption to the ward activities; student nurses delicately but quickly cover the bodies of patients that have passed away, nurses continue with their duties and parents continue on with their lives. Sometimes not even tears are shed. At one point last week I was concerned that not even the practical exams for the student nurses that were taking place in the centre of the open ward would be stopped as a man took his last breath. (Thankfully they did decide to have a temporary pause in the proceedings although this was seen as being particularly kind.)  As an outsider I find it difficult to keep the balance between, on one hand, wanting to remain appalled and shocked at the current situation of an almost daily routine of loss of life, but on the other hand, needing not to be so horrified that you cannot function when the next child is carried through the door who needs assessing and treating. I apologise if these ponderings are an outlet to keep that balance in check.



The new shower...

Last month we were in Freetown to visit the medical council. Although our hotel didn’t quite hit the five star mark, it did have a trickle of cold running water from a rusty shower head. To us this was luxury. The simple matter of removing the need for one hand to be occupied with pouring water from a jug to wash improved the ablution experience considerably. Since then I have spent several hours in our ‘bathroom’ in Segbwema trying to construct a ‘shower’ from a 5L plastic container, rope and dental floss; all quality products purchased in ‘Poundland’ before our departure. Those who are acquainted with my DIY skills will be unsurprised to hear that thus far, results have been mixed. A palliative care consultant when teaching on how difficult it is to judge what one person views as “quality of life” once stated to me that quality of life is about how near a person’s expectations are met by the events of their daily life. Whilst a hot shower sounds appealing, when you have no anticipation of any running water, a trickle of cold water from a shower head certainly exceeds expectations and improves your quality of life.  Whilst not wanting to demean the devastation and misery of women in Segbwema who have children still born or who die very young, realising how these events fit with their expectations of pregnancy, child birth and motherhood can perhaps help to understand their perspective on what we, as outsiders, may view as life shattering events and explain the resilience with which they cope. Ultimately, expectations need to be changed but this is neither quick nor simple.



All is not bleak and life here is filled with moments of both enjoyment and humour. I still find it difficult not to conceal a wry smile when male patients seen in clinic do not respond to the translated line of ‘What’s the problem?’ or ‘How can I help?’ but simply stand up and pull down their trousers to reveal enormous hydroceles (swellings around the testicles) the size of large grapefruits. (How childish of me I know...) There is also time to enjoy the simple pleasures of sitting on the steps outside our house drawing with an ever growing gathering of children who have now discovered our supplies of paper and colouring pencils, or walking home down the hill with Amie, the 6 year old granddaughter of one of the nurses who Janna is helping to read, or honing our scrabble skills and successfully placing ‘JUICY’ onto a triple word score (51).  One of the happiest times of the day is early evening when I walk down to the TB ward and see an ever improving Evelyn smiling and enthusiastically returning my wave through the open wooden shutters to the ward.




Shutters of the TB ward

I listened with interest this week on the world service as promising results of trials of a malaria vaccine were publicised. Although such progress is undoubtedly good news, Benjamin Franklin conducted extensive research on electricity in the 18^th century and a few hundred years on the hospital only has the resources and infrastructure to provide electricity less than 10% of the time. I hope it doesn’t take as long to get the malaria vaccine coverage up to this level here.
How fitting, the power has just gone off for the night…..