Author: Nomadobgyn

Throughout my training, I have been drawn to organizations or institutions that have a mission to serve the underserved.  To start with… I attended a college that was founded by a Saint!  Katherine Drexel, born to a wealthy family, instead of spending her fortune on finite possessions she chose to join the Sisters of the Blessed Sacrament and dedicated her life to improving the lives of black and brown children in the South.  The Salt Wagon Story describes an act of kindness, which prompted Samuel Meharry to found the medical college, where I eventually did my residency training. This legacy, started to educate a then disenfranchised Black American population in the South, continues to address health inequities in this country.

While in residency, our hospital served as the city’s safety net hospital.  Though we did care for insured patients, we also provided services for those under and uninsured populations of Nashville.   Tennessee at the time funded a state system called TennCare which worked to fill the gaps for small business owners or those who were unemployed.  However, there were those who still fell through the cracks and they came to us.  The hospital population included many Black American Women and Latina women, who bear a higher burden of uterine fibroids.  Fibroids are benign tumors of the womb that can cause heavy bleeding, pelvic pain and anemia.  Multiple treatment options exist, but the definitive treatment is still a major surgical procedure, a hysterectomy.  There were times when uninsured women could not schedule their surgery due to their inability to pay, literally going home with the fear of bleeding to death with their next period.   When I was looking for my first employed position, I chose to work for a group in Norristown, Pennsylvania, where one of their offices provided similar services for the women of that community.

Here in Mutomo, some patients have the National Health Insurance.  However, many still pay out of pocket for their care.  This week I cared for a young woman who had been transferred from another facility due to the infant being in breech presentation (specifically the foot was visible at the opening of the vagina).  She was rushed for cesarean section on arrival, she, and the infant recovered well.  On the day of discharge (day #4), the infant was noticed to have yellowing of the eyes.  We tested for and diagnosed him with neonatal jaundice. A relatively common condition of neonates that is treated with light therapy.  This treatment requires further hospitalization and monitoring, and therefore an increase in cost.  After two additional days in the hospital, the mother asked me if she could be discharged.  I said no, the bilirubin levels were still elevated.  She was visibly upset and frustrated with me.  I reassured her that it was in their best interest to stay.  I tried to explain (with the help of the nurse) that yes, her infant appears fine now.  But left untreated, neonatal jaundice can lead to serious complications.  She replied, “Daktari, you don’t understand…the bill.”

I get it.  I do understand.  In that moment I was disheartened that she thought I didn’t understand, but also that I could do nothing to change the dilemma that she faced.  Was it possible that she could go home and her newborn son would recover well?  Of course.  Was it also possible that if left untreated the condition would progress to cause seizures or brain damage?  Yes, of course.  In either case, why is it fair that a new mother has to weigh the mounting health care costs with the costs to her child’s health?

Many women, many people face these complicated decisions everyday in hospitals and clinics across the world.  I hope that this generation continues to move the needle forward toward supporting the basic right of universal health care coverage for all people.

After being in Kenya for 8 weeks, I thought I’d take the opportunity to share with you 8 of my favorite photos from my time here.

Typically, my clinical responsibility ends at birth.  When all things go well, after guiding the mother through prenatal care, labor and delivery, I happily hand off the new bundle to the awaiting nursing or pediatric staff.  I congratulate the parents and wish the baby “happy birthday”, before exiting the room to complete my notes.  Here in Mutomo, my responsibility is not over.  Normal newborns with no issues are assessed at birth and then discharged with their mothers to follow up as outpatients.  However, we admit those neonates with complications and they become part of the maternity service, i.e. my service.  As you can imagine, I had to tune up on my newborn medical knowledge.

My second week on service, as I finished rounds, I was called to evaluate an infant who had been doing poorly for the last few days.  He had been diagnosed with meconium aspiration and neonatal sepsis.  The treatment regimen included antibiotics and supplemental oxygen.  Over the previous few days, he had increasing difficulty breathing and maintaining his oxygen levels.  One of the nurses was actively trying to resuscitate the infant when I arrived; I assisted but felt at a loss in offering any additional support.  As we watched the oxygen saturation levels drop into the 30’s, the infant was barely responsive to stimuli and losing muscle tone.  I asked for one of the other doctors to come to assess the situation, he then relieved me so that I could report to the major theatre (OR) for a case.  I learned soon thereafter, he pronounced the infant and consoled the family.  A few weeks later, I was walking past the maternity unit on my way to dinner and I heard, “Dr. Mary, can you stop in?”  One of our admitted infants, born to a mother the day prior after a difficult vacuum assisted delivery, no longer had a heartbeat, no longer showed any evidence of respiratory effort, no longer… She called me to write the note to certify death.  As an Ob/Gyn, we handle difficult situations more often than we would like.  I have diagnosed miscarriages and stillbirths however this was the first time I pronounced death after delivery.  The discussion of a death of child with a mother, whether at 8 weeks, 36 weeks or 2 days after birth isn’t comfortable.  It doesn’t get easier with time.  There are no consoling words.

During residency and then as a public health student, I developed an interest in how I could work to reduce infant mortality, both locally and globally.  One of the health predictors of a country is linked to how well the newest members of its population fare after birth, more specifically, infant mortality is the number of infant deaths before his or her first birthday.  As advanced as health care is in the United States, we still do a subpar job in protecting one of our most vulnerable populations.  In 2010, the infant mortality rate in the United States was 6.1 deaths per 1,000 live births. To compare, the rate in Finland was 2.3, France 3.6 and England 4.1.  The discrepancy between populations in the United States is even more disheartening.  We see a large gap in the rates of infant mortality between white and black women; the most recent data reveals a rate of 11.3 (which translates to a ratio of 2 to 1).

One way to combat this problem for me clinically is by providing comprehensive, appropriate care for women, especially reproductive age women.  The best prenatal care starts at pre-conception and continues into the pregnancy.  However, we know that adequate medical care is not sufficient and even when controlling for education and income, black women in the US still have increased rates of infant mortality.  Studies have confirmed that stress plays a factor in these outcomes, especially the stress due to the consequences of racism in the United States.  See the link to the PBS special entitled Unnatural Causes.

In Kenya, the infant mortality rate is 38.3 per 1,000.  According to the WHO, “the main causes of newborn deaths are prematurity and low-birth-weight, infections, asphyxia (lack of oxygen at birth) and birth trauma. These causes account for nearly 80% of deaths in this age group.” CMMB through its CHAMPS (Children and Mothers Partnerships) program has collaborated with Mutomo Mission hospital to combat this situation in sub-county of Kutui South.   Interventions include promoting antenatal care, training community health volunteers, supporting community health centers, providing equipment and supplies, in addition to enlisting the aid of volunteer doctors and nurses.  I can see the results of this program when taking the history of our patients in labor and delivery.  Women who have traditionally delivered at home are now seeking care in a skilled facility and pursue referral earlier if complications arise.

The public health community has made great strides to reduce infant mortality and the rates have decreased.  But there is still much work to be done at home and abroad.  Though I don’t have any biological children, I experienced pregnancy and childbirth alongside two of my closest friends.  I am now blessed with two godchildren who are healthy and happy.  I hope my work, in some way, allows more women to experience the same blessings.

Moja= Swahili for One

http://www.who.int/mediacentre/factsheets/fs333/en/

https://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_05.pdf

http://www.pbs.org/unnaturalcauses/hour_02.htm

https://www.cia.gov/library/publications/the-world-factbook/fields/2091.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4158907/

Mutomo, Kenya

One of my favorite parts of traveling is sampling the local cuisine and I often collect spices, recipes or cookbooks in order to re-create the meals at home.  Over the past year I’ve spent quite a bit of time working in Norway, Maine.  Though not what you’d call a food destination, the community there prides itself on supporting local farmers in both in their homes and in the local restaurants. I enjoy shopping at the neighborhood co-op, but even the commercial grocery store displays a wide variety of local items.  I was fortunately in town this year for the annual food festival held in August.  The festival showcased fresh produce, food trucks with Maine classics and information on food waste as well as how to support the vendors in the future.  As a bonus, it was headlined by Carolyn Costanzi and the Cobblestones, (you may remember her from an earlier post, Ob/Gyn by day, Rockstar by night). Because my travel to Kenya would affect my assignment there, she knew I would be spending 6 months in East Africa.  She said, “you should meet my neighbor, he’s from Kenya.  I’ll have party, invite everyone over.”  Who says no to that!  True to her word, Carolyn hosted several of us for dinner, complete with Western Maine grown fruits and vegetables, regional sausages and homemade ice cream.

In turn, Dexter and his wife Jenna, invited us over for to try a few traditional Kenyan dishes. Jenna, originally from Massachusetts, was volunteering in Kenya, when the couple met.  They relocated to the states where Dexter completed his dentistry training on the east coast and have now settled in Norway with their three children.  They each shared their personal experiences, and though they had not been to Mutomo, (or heard of it even) they described generally what my expectations should be of the country.  One of the most important of those…food! They prepared a meal of goat, ugali and kachumbari.  We also had chai (or tea, made with milk and sugar).  I greatly enjoyed the meal and truly appreciated their efforts to help me prepare for a smooth transition.

A frequent question when I first arrived was, “you know ugali?”  Thanks to them, I could respond in the affirmative. “Yes, yes I do.”  And, Kenyans love their ugali.  It’s a staple dish, made from maize meal and often served shaped in a mound or ball, ugali can be served with all meals.  Usually the question asked when ordering a meal is, “What would you like with your ugali?”  Up for a challenge, I even attempted to make my own ugali last weekend, which requires patience and forearm fortitude.  The maize mixture is poured into boiling hot water and stirred frequently with a wooden spoon until you achieve the correct consistency.  A restaurant (and I’m sure a home) will be judged by the consistency of your ugali.  I would describe it as somewhere between polenta and cornbread.  It’s soft, but firm enough to be cut with a fork or knife.  Mine is a work in progress, but I think it turned out well for my first try!

In Mutomo, I take most of my meals in the canteen which serves as the hospital cafeteria.  Ran by a local restaurateur, Nameless Café II, has a standard Kenyan menu.  For breakfast, I have an Andazi and chai.  An andazi reminds me of a beignet without the powdered sugar.  Only slightly sweet, it less rich than an American doughnut, but sweeter than bread.  A typical afternoon or evening meal will consist of nyama choma, cabbage, ugali or chapati.  Nyama choma refers to grilled or roasted meat that can be served in sauce.  Chapati is a wheat flour flatbread, which I would describe as a cross between naan and a tortilla.  Now a favorite side dish of mine is kachumbari.  Light and refreshing, it’s a tomato and onion salad, that may include avocado when in season.  It’s most similar to pico de gallo and at times includes hot peppers as well.

When I expressed concern about whether I would enjoy the food here, Dexter and Jenna reassured me that Kenyan food is very flavorful and filling.  And they are indeed correct!